Nokea
When caring for patients with hyperbilirubinemia, the nursing care plan should focus on the following, EXCEPT_________.
- A. informing appropriately the significant others
- B. preventing injury
- C. maintaining physiological homeostasis with bilirubin levels increasing
- D. preventing complications.
Correct Answer: C
Rationale: When caring for patients with hyperbilirubinemia, the nursing care plan should focus on informing the significant others, preventing injury, and preventing complications. The primary goal in managing hyperbilirubinemia is to prevent complications associated with high bilirubin levels, such as kernicterus. Therefore, maintaining physiological homeostasis with bilirubin levels increasing would not be appropriate and should not be the focus of the nursing care plan. It is crucial to monitor and manage bilirubin levels to prevent adverse outcomes rather than allowing them to increase.
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A patient presents with a pruritic, erythematous rash with edematous plaques and vesicles on the hands and fingers. The patient reports a history of exposure to detergents and frequent hand washing. Which of the following conditions is most likely responsible for this presentation?
- A. Atopic dermatitis
- B. Contact dermatitis
- C. Psoriasis
- D. Pityriasis rosea
Correct Answer: B
Rationale: The presentation of a pruritic, erythematous rash with edematous plaques and vesicles on the hands and fingers in a patient with a history of exposure to detergents and frequent hand washing is most indicative of contact dermatitis. Contact dermatitis can be caused by direct contact with irritants such as detergents or chemicals, leading to skin irritation and inflammation. In this case, the history of exposure to detergents and hand washing suggests that the rash is likely due to irritant contact dermatitis. Atopic dermatitis, psoriasis, and pityriasis rosea do not typically present with the same pattern of rash in response to irritant exposure.
You encounter a conscious adult choking on a piece of food. The person is coughing forcefully but unable to speak or breathe effectively. What is the most appropriate action?
- A. Encourage continued coughing.
- B. Perform abdominal thrusts (Heimlich maneuver).
- C. Deliver back blows.
- D. Administer rescue breaths.
Correct Answer: B
Rationale: The most appropriate action in this situation is to perform abdominal thrusts, also known as the Heimlich maneuver. This technique is used to clear a blocked airway caused by a choking obstruction. Encouraging continued coughing may not be effective if the person is unable to dislodge the obstruction on their own. Delivering back blows can sometimes be effective, but abdominal thrusts are more commonly recommended in cases of choking in adults. Administering rescue breaths is not recommended if the person is conscious and able to cough, as it may worsen the situation by pushing the obstruction further down. By quickly performing abdominal thrusts, you can help dislodge the obstruction and potentially save the person's life.
Which clinical manifestation should Nurse Rachel watch for patient Claire if she is suffering from hyperthyroidism?
- A. Cold extremities
- B. Decreased bowel movement
- C. Fine motor tremor
- D. Increased weight
Correct Answer: C
Rationale: Hyperthyroidism is a condition where the thyroid gland produces an excess amount of thyroid hormone. One of the clinical manifestations of hyperthyroidism is a fine motor tremor, which is characterized by hand tremors or shaky movements in the fingers. This tremor is often more noticeable when the individual is trying to perform delicate tasks requiring fine motor skills. It is important for Nurse Rachel to watch for this symptom in patient Claire as it can impact her ability to perform daily activities and may require intervention or management strategies to help alleviate the tremor and improve quality of life.
Identify the primary indicator that Nurse Mary observes FIDELITY in the practice of her profession.
- A. Faithfully promotes health and prevents desease.
- B. Frequently assists in providing health services.
- C. Fairly evaluates health programs and initiatives.
- D. Collaborates and works with barangay officials.
Correct Answer: A
Rationale: The primary indicator that Nurse Mary observes FIDELITY in the practice of her profession is that she faithfully promotes health and prevents disease. Fidelity in nursing practice refers to being faithful, loyal, and committed to providing the best care and services to patients. By faithfully promoting health and preventing disease, Nurse Mary demonstrates her dedication to her profession, her patients, and the community she serves. This commitment includes following evidence-based practices, upholding ethical standards, being honest and trustworthy, and ensuring the well-being of those under her care. Ultimately, fidelity in nursing practice builds trust and confidence among patients, families, and colleagues, leading to better health outcomes and a stronger healthcare system.
A patient undergoing mechanical ventilation in the ICU develops ventilator-associated pneumonia (VAP) caused by multidrug-resistant organisms (MDROs). What intervention should the healthcare team prioritize to manage the patient's infection?
- A. Administer combination antibiotic therapy targeting MDROs.
- B. Perform bronchoalveolar lavage for diagnostic purposes.
- C. Implement strict isolation precautions to prevent transmission.
- D. Recommend prophylactic antifungal therapy to prevent candidiasis.
Correct Answer: A
Rationale: The most appropriate intervention for managing ventilator-associated pneumonia (VAP) caused by multidrug-resistant organisms (MDROs) is to administer combination antibiotic therapy targeting the specific resistant pathogens identified in the patient's culture results. MDROs are often resistant to multiple antibiotics, so combination therapy is required to maximize the chances of effectively treating the infection. Identifying the specific pathogens causing the VAP through cultures is crucial in tailoring the antibiotic therapy to target these organisms effectively. Implementing appropriate antibiotic therapy promptly is essential to improve outcomes and prevent further complications in patients with VAP caused by MDROs. Option A is the priority intervention in this case to address the multidrug-resistant nature of the infection and provide targeted treatment for the patient.