Nursing Elites

1. A client has developed thrombophlebitis of the left leg. Which nursing intervention should be given the highest priority?

• A. Elevate leg on 2 pillows
• B. Apply support stockings
• C. Apply warm compresses
• D. Maintain complete bed rest

Correct answer: A

Rationale: The highest priority nursing intervention for a client with thrombophlebitis of the left leg is to elevate the leg on 2 pillows. Elevating the leg helps reduce swelling and pain associated with thrombophlebitis by promoting venous return. Applying support stockings (choice B) can be beneficial but is not the highest priority as elevation is more effective in the acute phase. Applying warm compresses (choice C) may worsen the condition by dilating the blood vessels, leading to increased pain and swelling. Maintaining complete bed rest (choice D) is important, but elevation takes precedence to improve circulation and reduce the risk of complications.

2. The nurse is evaluating the growth and development of a toddler with AIDS. The nurse would anticipate finding that the child has

• A. Achieved developmental milestones at an erratic rate
• B. Delay in musculoskeletal development
• C. Displayed difficulty with speech development
• D. Delay in achievement of most developmental milestones

Correct answer: D

Rationale: Children with AIDS often experience delays in achieving developmental milestones, affecting their overall growth and development. This delay can impact various areas of development, not limited to a specific aspect like musculoskeletal or speech development. While some children may achieve milestones at varying rates (choice A), the general trend is a delay in multiple milestones (choice D). Musculoskeletal development (choice B) and speech development (choice C) may be affected but are not as comprehensive as the delay in most developmental milestones.

3. In planning the use of resources for secondary prevention in a community clinic serving migrant families, which activity should be the priority?

• A. Skin testing for tuberculosis.
• B. Glucose monitoring for diabetes.
• C. Blood work for cardiovascular disease.
• D. Height and weight for altered nutrition.

Correct answer: A

Rationale: The correct answer is A: Skin testing for tuberculosis. In a community clinic serving migrant families, tuberculosis is a significant health concern due to close living conditions and potential exposure during migration. Skin testing for tuberculosis is crucial for secondary prevention as it helps in early detection and prevention of the spread of the disease within the community. Choices B, C, and D are important health screenings but may not be the priority in this specific population where tuberculosis poses a higher risk.

4. A 23-year-old single client is in the 33rd week of her first pregnancy. She tells the nurse that she has everything ready for the baby and has made plans for the first weeks together at home. Which normal emotional reaction does the nurse recognize?

• A. Acceptance of the pregnancy
• B. Focus on fetal development
• C. Anticipation of the birth
• D. Ambivalence about pregnancy

Correct answer: C

Rationale: The correct answer is C: 'Anticipation of the birth.' In the third trimester, it is common for expectant mothers to feel excited and prepared for the upcoming birth of their baby. This includes making plans for the baby's arrival and the early days at home. Choice A, 'Acceptance of the pregnancy,' may occur earlier in the pregnancy and does not specifically relate to the third trimester. Choice B, 'Focus on fetal development,' is more common in the earlier stages of pregnancy when the mother may be more concerned with the baby's growth and milestones. Choice D, 'Ambivalence about pregnancy,' suggests conflicting feelings which are less likely in this scenario where the client expresses readiness and plans for the baby's arrival.

5. Under the local government code, health services must be developed by the local governments. This means that local health agencies such as health centers/rural health centers must be under the:

• A. municipal government office
• B. barangay health councils
• C. district health office
• D. provincial health office

Correct answer: A

Rationale: The correct answer is A: municipal government office. According to the local government code, local health agencies like health centers and rural health centers are managed by the municipal government office. This is because the municipal government is responsible for providing essential public services within their jurisdiction. Choice B, barangay health councils, is incorrect as they operate at a smaller administrative level than municipal government offices. Choice C, district health office, is not the correct level of government responsible for managing local health agencies. Choice D, provincial health office, is at a higher administrative level than the municipal government office and is not directly responsible for managing local health agencies.

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