Nursing Elites

1. A 67-year-old client is admitted with substernal chest pain with radiation to the jaw. His admitting diagnosis is Acute Myocardial Infarction (MI). The priority nursing diagnosis for this client during the immediate 24 hours is

• A. Constipation related to immobility
• B. High risk for infection
• C. Impaired gas exchange
• D. Fluid volume deficit

Correct answer: C

Rationale: The correct answer is C: Impaired gas exchange. In a client with an acute myocardial infarction, impaired gas exchange is a priority nursing diagnosis due to compromised heart function, which affects oxygenated blood circulation. Close monitoring and interventions are crucial to ensure adequate oxygenation. Choices A, B, and D are incorrect: A) Constipation related to immobility is not the priority in this acute situation; B) High risk for infection is not the immediate concern related to the client's primary diagnosis; D) Fluid volume deficit, while important, is not the priority compared to addressing impaired gas exchange in acute MI.

2. The Philippine Family Program seeks to improve and maintain which of the following life-saving measures?

• A. proper spacing of pregnancies
• B. proper timing of pregnancies
• C. fewer pregnancies
• D. all of the above

Correct answer: D

Rationale: The correct answer is D, all of the above. The Philippine Family Program aims to enhance and sustain proper spacing of pregnancies, proper timing of pregnancies, and reducing the number of pregnancies. These measures are essential for promoting maternal and child health, preventing complications, and ensuring better outcomes. Choices A, B, and C are all part of the comprehensive approach taken by the program to safeguard the well-being of families and contribute to overall public health.

3. A newborn presents with a pronounced cephalic hematoma following a birth in the posterior position. Which nursing diagnosis should guide the plan of care?

• A. Pain related to periosteal injury
• B. Impaired mobility related to bleeding
• C. Parental anxiety related to knowledge deficit
• D. Injury related to intracranial hemorrhage

Correct answer: C

Rationale: The correct nursing diagnosis to guide the plan of care for a newborn with a pronounced cephalic hematoma following a birth in the posterior position is 'Parental anxiety related to knowledge deficit.' This is appropriate because the parents may be worried about the appearance and potential complications of the cephalic hematoma. They may require education and reassurance from the nurse. Choices A, B, and D are incorrect because they do not address the emotional needs of the parents and the knowledge deficit they may have regarding the condition.

4. The nurse is teaching childbirth preparation classes. One woman asks about her rights to develop a birthing plan. Which response made by the nurse would be best?

• A. "What is your reason for wanting such a plan?"
• B. "Have you talked with your health care provider about this?"
• C. "Let us discuss your rights as a couple."
• D. "Write your ideal plan for the next class."

Correct answer: C

Rationale: Discussing the rights as a couple allows for open communication and helps ensure that the birthing plan aligns with the couple's preferences and medical advice.

5. Which of these statements by the nurse is incorrect to use to reinforce information about cancers to a group of young adults?

• A. "You can reduce your risk of this serious type of stomach cancer by eating lots of fruits and vegetables, limiting red meat, and avoiding nitrate-containing foods."
• B. "Prostate cancer is the most common cancer in American men, impacting sexuality and life quality."
• C. "Colorectal cancer is the second-leading cause of cancer-related deaths in the United States."
• D. "Lung cancer is the leading cause of cancer deaths in the United States. However, it is the most preventable of all cancers."

Correct answer: A

Rationale: The corrected statement in choice A emphasizes limiting red meat for the prevention of stomach cancer, which is more accurate than avoiding all meats. By focusing on red meat specifically, it provides clearer guidance to young adults. Choice B is not the correct answer as it provides accurate information about prostate cancer being the most common cancer in American men and its impact on sexuality and life quality. Choice C is also a valid statement, correctly highlighting colorectal cancer as the second-leading cause of cancer-related deaths in the United States. Choice D provides accurate information about lung cancer being the leading cause of cancer deaths in the United States and emphasizes its preventability among cancers, making it a valid statement for reinforcing information about cancers to young adults.

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