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The nurse ensures, which of the following should be present and be cooperative in the educational program?
- A. Patient, student nurses and interns
- B. Patient, family and significant others
- C. Head nurse and family
- D. New staff nurses and nursing aides of the unit
Correct Answer: B
Rationale: In an educational program conducted by a nurse, it is crucial to involve the patient, their family, and significant others. This approach ensures holistic care by considering the patient's psychosocial environment, family dynamics, and support system. Including these individuals in the educational program fosters collaboration, strengthens the patient-nurse relationship, and equips family members with the knowledge and skills needed to provide optimal care at home. Furthermore, involving the patient's support system can enhance adherence to treatment plans and contribute to better health outcomes. Therefore, the presence and cooperation of the patient, family, and significant others are essential elements of a successful educational program led by a nurse.
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The patient verbalizes to the nurse about thought to kill his wife". The nurse is in dilemma whether to tell the wife about this Conversation. Given this situation which of the following is the appropriate action of the nurse?
- A. Alert immediately the proper authorities regarding the threat to safeguard the safety of the wife.
- B. Tell the wife to be very extra careful as her life is danger.
- C. Weigh carefully the situation by viewing it as dilemma between disclosing confidential information or warning appropriate authorities.
- D. Keep the information to herself and be vigilant on action of the patient to protect the wife
Correct Answer: A
Rationale: In this critical situation, the safety of the wife is of utmost importance. Whenever a healthcare provider becomes aware of a direct threat to someone's safety, especially related to potential harm or violence, it is their ethical and legal responsibility to report this information to the appropriate authorities promptly. In this case, the nurse should alert the proper authorities, such as law enforcement or a mental health crisis team, to ensure that immediate steps are taken to protect the wife from harm. Confidentiality should be breached in situations where there is a clear threat to an individual's safety. Keeping the information confidential in this scenario could result in serious harm or even loss of life. The nurse must act quickly to protect the potential victim.
A postpartum client presents with persistent, severe perineal pain despite analgesic medication. On assessment, the nurse observes ecchymosis and swelling of the perineum. Which nursing action is most appropriate?
- A. Applying ice packs to the perineum for pain relief
- B. Encouraging the client to sit on a donut cushion
- C. Notifying the healthcare provider immediately
- D. Administering additional analgesic medication
Correct Answer: C
Rationale: The presence of persistent, severe perineal pain along with ecchymosis and swelling of the perineum can indicate a complication such as a hematoma. A hematoma is a collection of blood that can occur in the perineal area postpartum, usually as a result of trauma during delivery. It is essential to notify the healthcare provider immediately to assess the situation, provide appropriate treatment, and prevent further complications. Applying ice packs or administering additional analgesic medication may not address the underlying issue of a possible hematoma, so prompt medical evaluation is crucial in this situation.
The nurse prepares a care plan for the patient. Based on Ramona Mercer's becoming a mother (BAM) theory, which of the following statements fosters the process of becoming a mother?
- A. The woman becomes comfortable with her identity as a married individual.
- B. It encompasses the dynamic transformation and evolution of a woman's persona.
- C. A woman learns mothering behavior prior as early as a teenager.
- D. It accurately reflects the transitional process from being single to a married relationship.
Correct Answer: B
Rationale: Ramona Mercer's becoming a mother (BAM) theory emphasizes the dynamic transformation and evolution of a woman's persona as she transitions into motherhood. This theory acknowledges that becoming a mother is a process involving significant changes in a woman's identity, roles, and relationships. It goes beyond just the physical aspects of giving birth and delves into the psychological, emotional, and social aspects of motherhood. Therefore, statement B aligns with the core principles of Mercer's BAM theory and fosters the understanding of the process of becoming a mother.
A patient in the ICU develops catheter-related bloodstream infection (CRBSI) associated with a central venous catheter. What intervention should the healthcare team prioritize to manage the patient's infection?
- A. Remove the central venous catheter to eliminate the source of infection.
- B. Administer broad-spectrum antibiotics targeting common pathogens.
- C. Perform blood cultures to identify the causative organism.
- D. Implement sterile dressing changes and catheter care protocols.
Correct Answer: A
Rationale: The primary intervention that should be prioritized for managing a catheter-related bloodstream infection (CRBSI) associated with a central venous catheter is to remove the central venous catheter. CRBSI is a serious complication that can lead to severe infections and sepsis. The removal of the catheter is crucial to eliminate the source of the infection and prevent further dissemination of the pathogens into the bloodstream. Once the catheter is removed, the healthcare team can consider other interventions such as administering targeted antibiotics based on culture results, performing blood cultures to identify the causative organism, and implementing sterile dressing changes and catheter care protocols. However, immediate removal of the catheter takes precedence in managing CRBSI to prevent worsening of the infection and improve patient outcomes.
To obtain her license to practice, she must do the following, EXCEPT:
- A. Must take the path to any government official
- B. Must register in the registration division of the PRC
- C. Must take the oath of professionals before any member of the PRBON
- D. Must be issued a certificate of Registration (COR) and profession identification card (PIN)
Correct Answer: A
Rationale: To obtain a license to practice, the individual must follow certain steps and fulfill specific requirements. Option A states that she must take the path to any government official, which is not accurate or necessary in the process of obtaining a professional license. The other options provided are correct in the usual process of getting a license: registering in the Professional Regulation Commission (PRC), taking the oath of professionals before a member of the Professional Regulatory Board of Nursing (PRBON), and being issued a certificate of Registration (COR) and a profession identification card (PIN).