Nokea
Which of the following tools used by nurses in the community setting for assessing health needs and problems of families that is similar to family coping index
- A. Nursing theories
- B. Vitals statistics
- C. Case study
- D. Nursing diagnosis
Correct Answer: D
Rationale: Nursing diagnosis is the tool used by nurses in the community setting for assessing health needs and problems of families that is similar to the family coping index. Nursing diagnosis involves systematic assessment of a patient's health status, analysis of data, and identification of actual or potential health problems. Just like the family coping index, nursing diagnosis helps nurses to identify key issues and develop a plan of care that addresses the specific needs and challenges faced by the family. This process allows nurses to provide individualized care that supports the family in coping with their health needs and improving their overall well-being.
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A risk is any event that causes problems or benefits on the healthcare institution. The Medical Director knows that potential risks must be identified across the hospital in order to prevent the following, EXCEPT
- A. financial loss
- B. accidents
- C. incident reports
- D. injuries
Correct Answer: C
Rationale: Incident reports are a crucial tool for capturing data on adverse events, near misses, and other incidents within a healthcare institution. These reports help in analyzing patterns, identifying areas for improvement, and implementing quality and safety measures. Therefore, incident reports themselves are not something that needs to be prevented; instead, they are a critical part of the risk management process to enhance patient safety and quality of care.
Mr. C is an older patient with a known history of peripheral vascular disease. The nurse places a heating pad directly on the patient's lower leg to relieve muscle spasms. The heating pad causes a burn, the area becomes infected, and the patient eventually must have a skin graft. This is an example of which of the following?
- A. Malpractice
- B. Vicarious liability
- C. Assault
- D. Negligence
Correct Answer: D
Rationale: Negligence refers to the failure to take proper care in doing something. In this scenario, the nurse failed to exercise the standard of care expected in placing a heating pad directly on Mr. C's lower leg, knowing his history of peripheral vascular disease. This failure led to a burn and subsequent infection that required a skin graft for treatment. The actions of the nurse were negligent as they did not meet the expected standard of care, resulting in harm to the patient. This situation does not fit the definition of assault, malpractice, or vicarious liability, making negligence the most appropriate choice.
The last fire in the hospital was due to a malfunctioning equipment. The Fire extinguisher was nowhere to be found. What should have been practiced?
- A. A dedicated fire extinguisher must be in every strategic Place
- B. Place one fire extinguisher between two units.
- C. A fire extinguisher can be replaced with fire sensors.
- D. Borrowing fire extinguishers may be tolerated if on the same floor
Correct Answer: A
Rationale: The correct practice in this situation would be to have a dedicated fire extinguisher in every strategic location throughout the hospital. Having fire extinguishers readily available in key areas ensures that they can be accessed quickly in case of a fire emergency. Placing one fire extinguisher between two units may not be sufficient as it may not be easily accessible in the event of a fire. Fire extinguishers should not be replaced with fire sensors as these serve different functions. Additionally, borrowing fire extinguishers may not be a safe or reliable practice, as they should be properly maintained and placed according to safety standards. Therefore, having dedicated fire extinguishers in every strategic location is the best practice to ensure the safety and well-being of individuals in the hospital.
A woman in active labor is experiencing prolonged rupture of membranes (>24 hours). What complication should the nurse assess for in the mother and fetus?
- A. Intrauterine infection
- B. Fetal macrosomia
- C. Placental abruption
- D. Maternal hypotension
Correct Answer: A
Rationale: Prolonged rupture of membranes (>24 hours) increases the risk of intrauterine infection for both the mother and the fetus. When the amniotic sac has been ruptured for an extended period, there is a higher likelihood of bacteria entering the uterus, leading to chorioamnionitis (inflammation of the fetal membranes due to infection). Intrauterine infection can be dangerous for both the mother and fetus, potentially causing sepsis, preterm labor, and other complications. Therefore, it is crucial for the nurse to assess for signs and symptoms of infection in both the mother and fetus when managing a woman in active labor with prolonged rupture of membranes.
When the patient turned 69 years old, Orinase was discontinued and NPH insulin is prescribed for her. After several months, she is determined to be suffering from sumogyi effect. Which of the following conditons will most likely result when the patient is receiving too much insulin?
- A. Developing an elevation of the blood glucose level
- B. Producing even more insulin
- C. Becoming resistant to insulin
- D. Conserving excessive amount of fluid
Correct Answer: A
Rationale: When a patient is receiving too much insulin, the most likely result is hypoglycemia, not hyperglycemia. The excess insulin causes the blood glucose level to drop too low, leading to symptoms such as sweating, tremors, confusion, and in severe cases, seizures. The body responds to hypoglycemia by releasing counterregulatory hormones such as glucagon, epinephrine, and cortisol, which work to increase the blood glucose level. This rebound effect, known as the Somogyi effect, can result in the patient experiencing high blood glucose levels after a period of insufficient glucose supply due to excessive insulin administration.