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Upon data collection he had been failing three times in his math class and Korino was known for substance dependent for three years. What is the MOST APPROPRIATE nursing diagnosis for him?
- A. Alteration in perception.
- B. Ineffective individual coping.
- C. Alteration in social interaction.
- D. Impaired judgment.
Correct Answer: B
Rationale: The most appropriate nursing diagnosis for the individual described is "Ineffective individual coping." This is because the individual has been facing challenges in both academic (failing math class) and personal (substance dependence) aspects of his life. The repeated failures in his math class and the substance dependence for three years indicate that he might be struggling to cope with stressors and challenges in his life effectively. By identifying this nursing diagnosis, the nurse can focus on helping the individual develop effective coping strategies to manage and overcome these difficulties.
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A woman in active labor experiences frequent and intense uterine contractions with minimal rest intervals, leading to maternal fatigue and decreased fetal oxygenation. What maternal condition should the nurse assess for that may contribute to this abnormal labor pattern?
- A. Maternal dehydration
- B. Uterine hyperstimulation
- C. Pelvic outlet obstruction
- D. Maternal exhaustion
Correct Answer: B
Rationale: Uterine hyperstimulation, also known as tachysystole, is a condition where the uterus contracts too frequently and/or too forcefully, leading to a decreased uterine blood flow. This can result in maternal fatigue and decreased oxygenation to the fetus, as mentioned in the scenario. Uterine hyperstimulation can be caused by several factors, including the excessive use of uterotonic medications, such as oxytocin, or the presence of uterine abnormalities.
What tasks can be delegated to his nursing assistant during his tour of duty.
- A. Changing wound dressings.
- B. Administering analgesic drug.
- C. Performing a physical assessment.
- D. Taking vital sign
Correct Answer: A
Rationale: A nursing assistant can be delegated the task of changing wound dressings because it is considered a basic nursing care activity that does not require specialized training or knowledge. Nursing assistants are trained to perform tasks related to personal care, hygiene, and basic wound care under the supervision of a registered nurse. Changing wound dressings is a routine nursing task that can be safely delegated to a nursing assistant, allowing the nurse to focus on other aspects of patient care that require specialized nursing skills and knowledge.
It mandates the compulsory Immunization of children below 8 years
- A. PD 996
- B. RA 11223
- C. RA 9173
- D. RA 10912
Correct Answer: C
Rationale: Republic Act 9173, also known as the Philippine Nursing Act of 2002, mandates the compulsory immunization of children below 8 years. This law ensures that young children receive necessary vaccines to protect them from preventable diseases and promote public health. RA 9173 is a significant legislation that highlights the importance of immunization in safeguarding the well-being of children in the Philippines.
A postpartum client reports severe perineal pain and difficulty passing stools following a vaginal delivery. Which nursing intervention should be implemented?
- A. Administering a stool softener as ordered
- B. Encouraging the client to refrain from defecation until pain subsides
- C. Applying ice packs to the perineum for pain relief
- D. Providing education on proper perineal hygiene
Correct Answer: A
Rationale: Administering a stool softener as ordered is the most appropriate nursing intervention for a postpartum client experiencing severe perineal pain and difficulty passing stools following a vaginal delivery. Stool softeners help to soften the stool, making it easier for the client to pass without straining, which can exacerbate perineal pain. It is important to follow the healthcare provider's orders when administering medications to ensure proper dosing and effectiveness. Encouraging the client to refrain from defecation may lead to constipation and worsen the situation. Applying ice packs to the perineum can provide temporary pain relief, but addressing the underlying issue of constipation with a stool softener is more effective in the long term. Providing education on proper perineal hygiene is important for overall postpartum care, but addressing the immediate issue of constipation with a stool softener takes precedence in this scenario.
A patient with a history of heart failure presents with dependent edema in the lower extremities. Which nursing action is most appropriate for managing the patient's edema?
- A. Applying compression stockings
- B. Elevating the legs above heart level
- C. Administering diuretics as prescribed
- D. Encouraging increased fluid intake
Correct Answer: C
Rationale: The most appropriate nursing action for managing a patient with dependent edema in the lower extremities is to administer diuretics as prescribed. Diuretics help the body remove excess fluid, reducing swelling and edema in the extremities. It is important to follow the healthcare provider's orders for administering diuretics to ensure the patient's fluid balance is managed effectively. While elevating the legs above heart level and applying compression stockings may provide temporary relief, addressing the underlying cause of fluid retention with diuretics is essential for long-term management of the edema in a patient with heart failure. Encouraging increased fluid intake would not be appropriate in this case, as the focus should be on reducing fluid overload rather than increasing fluid intake.