Nursing Elites

1. 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.

2. For Barangay Mabulaklak, you intend to conduct health education sessions for a group of mothers. Which of the following topics for discussion will be given least priority:

• A. proper selection and preparation of food
• B. handwashing before preparing food
• C. cutting children's fingernails short
• D. overcrowding and its effect

Correct answer: D

Rationale: The correct answer is D - 'overcrowding and its effect.' While overcrowding is an important topic, it will be given least priority compared to the other choices when conducting health education sessions for a group of mothers. Proper selection and preparation of food (Choice A) is crucial for ensuring adequate nutrition, handwashing before preparing food (Choice B) is essential for preventing foodborne illnesses, and cutting children's fingernails short (Choice C) is important for maintaining good hygiene. Overcrowding, although significant in the context of public health, might be considered less immediately relevant for a group of mothers in a health education session focused on more direct and practical aspects of family health and hygiene.

3. The milk code aims to ensure that:

• A. the public receives accurate information about breastmilk and breastfeeding
• B. health workers do not provide samples of infant formula to pregnant women or mothers of infants
• C. companies consistently recognize the superiority of breastmilk
• D. health workers do not accept any incentives from milk companies

Correct answer: C

Rationale: The correct answer is C because the milk code emphasizes that companies should always acknowledge the superiority of breastmilk over formula. Choice A is incorrect because the focus is not on the public receiving information, but rather on companies recognizing breastmilk's superiority. Choice B is incorrect as it addresses health workers' actions, not the companies' behavior. Choice D is incorrect as the milk code is primarily concerned with regulating companies' practices, not health workers' acceptance of incentives.

4. During a visit to the community health clinic, a 45-year-old Native American female, who has a BMI of 35, complains of changes in her vision. Which condition is most important for the RN to be aware of in the client's family history?

• A. Diabetes
• B. Glaucoma
• C. Hypertension
• D. Brain Tumor

Correct answer: A

Rationale: The correct answer is A: Diabetes. Given the client's Native American ethnicity, high BMI, and vision changes, diabetes is the most crucial condition for the nurse to be aware of in the client's family history. Diabetes is strongly associated with vision problems, especially diabetic retinopathy. Glaucoma (choice B) is a condition that affects the optic nerve and can lead to vision loss but is not as directly linked to the client's BMI and ethnic background. Hypertension (choice C) can also impact vision, but in this case, diabetes takes precedence based on the client's profile. Brain tumor (choice D) is less likely to be related to the client's BMI, ethnicity, and vision changes compared to diabetes.

5. The nurse is caring for a client admitted to the hospital with right lower lobe (RLL) pneumonia. On assessment, the nurse notes crackles over the RLL. The client has significant pleuritic pain and is unable to take in a deep breath in order to cough effectively.

• A. Impaired gas exchange related to acute infection and sputum production
• B. Ineffective airway clearance related to sputum production and ineffective cough
• C. Ineffective breathing pattern related to acute infection
• D. Anxiety related to hospitalization and role conflict

Correct answer: B

Rationale: The client's inability to effectively clear the airway due to pain and sputum production hinders the cough mechanism, making 'Ineffective airway clearance' the most appropriate nursing diagnosis. Although impaired gas exchange may occur due to the pneumonia, the immediate issue is the inability to clear the airway. 'Ineffective breathing pattern' does not address the specific issue of airway clearance. 'Anxiety' is not the priority when the focus should be on the physical complications of pneumonia.

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