Nursing Elites

1. A community health nurse is conducting a home visit to assess a family's health needs. What is the first step in this process?

• A. Develop a care plan
• B. Conduct a physical examination
• C. Establish rapport with the family
• D. Provide health education

Correct answer: C

Rationale: Establishing rapport with the family is crucial in the initial stages of a home visit. It helps build trust, open communication channels, and allows the nurse to gain insight into the family's health needs and concerns. Developing a care plan (Choice A) comes after the assessment phase, where information is gathered. Conducting a physical examination (Choice B) is a part of the assessment but typically follows establishing rapport. Providing health education (Choice D) is important but usually occurs after the assessment and care planning stages.

2. A client with chronic congestive heart failure should be instructed to contact the home health nurse if which finding occurs?

• A. Weight gain of 2 pounds or more in a 48-hour period
• B. Urinating 4 to 5 times a day
• C. A significant decrease in appetite
• D. Appearance of non-pitting ankle edema

Correct answer: A

Rationale: A rapid weight gain of 2 pounds or more in a 48-hour period may indicate fluid retention and worsening heart failure, requiring prompt medical evaluation and intervention. This finding is crucial in managing chronic congestive heart failure as it signifies a potential exacerbation of the condition. Choices B, C, and D are less concerning in this context. Urinating 4 to 5 times a day is within the normal range for most individuals and may not be directly related to heart failure. A significant decrease in appetite may be due to various factors and might not be an immediate cause for concern in heart failure patients. The appearance of non-pitting ankle edema, although related to heart failure, is a more chronic and less urgent symptom when compared to a rapid weight gain, which requires immediate attention.

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. In this municipality, what should the nursing health care plan focus on?

• A. Rehabilitative services
• B. All of these services
• C. Health promotion and disease prevention
• D. Curative services

Correct answer: C

Rationale: In this municipality, the nursing health care plan should primarily focus on health promotion and disease prevention. This approach addresses the underlying causes of health problems, promotes overall well-being, and helps prevent illnesses before they occur. While rehabilitative and curative services are important, health promotion and disease prevention are crucial for fostering a healthier community in the long term. Therefore, choices A, B, and D are not the best options as they do not prioritize preventing health issues at the root cause.

5. In combating myths and misconceptions about family planning in the community, what should you do first as a health educator?

• A. Identify the influential leaders of the community
• B. Select an approach to be used in correcting myths and misconceptions
• C. Decide who will be involved in the conference
• D. Identify myths and misconceptions prevailing in the community and their sources

Correct answer: D

Rationale: The correct answer is to identify myths and misconceptions prevailing in the community and their sources. This is the initial step in addressing misconceptions effectively. By understanding the specific myths and where they originate from, a health educator can tailor their approach to correct these misconceptions. Choice A is incorrect because while influential leaders can play a role, identifying myths comes first. Choice B is incorrect as selecting an approach should come after understanding the myths. Choice C is incorrect as deciding who will be involved in a conference is not the primary step in combating myths and misconceptions.

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