Nursing Elites

1. The multidisciplinary home health care team is discussing a female client diagnosed with Parkinson's disease. The home health care nurse reports the client is getting worse, and her husband is no longer able to care for her in the home. Which action should the home health nurse implement first?

• A. Request a chaplain to counsel the couple.
• B. Assign a home health care aide to provide daily care.
• C. Discuss placing the wife in a nursing home with the husband.
• D. Contact the client's children to discuss the situation.

Correct answer: B

Rationale: In situations where a client's condition worsens and the caregiver is no longer able to provide sufficient care, the first action to implement is to assign a home health care aide to provide daily care. This ensures that the client's immediate needs are met and that they receive proper care and support. Requesting a chaplain for counseling (Choice A) may be beneficial but is not the most urgent action. Discussing placing the wife in a nursing home (Choice C) should only be considered after assessing the client's needs and exploring all other options. Contacting the client's children (Choice D) can be helpful but does not address the immediate need for daily care that the client requires.

2. The nurse is assessing a newborn the day after birth. A high-pitched cry, irritability, and lack of interest in feeding are noted. The mother signed her own discharge against medical advice. What intervention is appropriate nursing care?

• A. Reduce the environmental stimuli
• B. Offer formula every 2 hours
• C. Talk to the newborn while feeding
• D. Rock the baby frequently

Correct answer: A

Rationale: The correct intervention is to reduce the environmental stimuli. In this scenario, the newborn is displaying signs of overstimulation and distress, which can be exacerbated by environmental factors. Offering formula every 2 hours (Choice B) may not address the underlying issue of overstimulation. Talking to the newborn while feeding (Choice C) and rocking the baby frequently (Choice D) may further stimulate the newborn, which is not appropriate in this case.

3. A client was admitted with a diagnosis of pneumonia. When auscultating the client's breath sounds, the nurse hears inspiratory crackles in the right base. Temperature is 102.3 degrees Fahrenheit orally. What finding would the nurse expect?

• A. Flushed skin
• B. Bradycardia
• C. Mental confusion
• D. Hypotension

Correct answer: C

Rationale: The correct answer is C: Mental confusion. In this scenario, the client's high fever and pneumonia diagnosis indicate an infection. Infections, especially in older adults, can lead to mental confusion due to the body's systemic response to the infection. Flushed skin (choice A) is more commonly associated with fever but does not specifically relate to the client's condition. Bradycardia (choice B) and hypotension (choice D) are less likely findings in a client with pneumonia and a high fever; instead, tachycardia and increased blood pressure are more commonly seen in response to infection.

4. 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.

5. A 16-month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her, and begins to cry. What would be the initial action by the nurse?

• A. Arrange for a change in client care assignments
• B. Explain that this behavior is expected
• C. Discuss the appropriate use of 'time-out'
• D. Explain that the child is in need of extra attention

Correct answer: B

Rationale: The correct answer is to explain that this behavior is expected. At 16 months of age, children commonly experience separation anxiety, especially in unfamiliar environments like hospitals. It is important for the nurse to reassure the child and the parent that such behavior is normal. Option A is incorrect as there is no need to change client care assignments based on the child's behavior. Option C is not appropriate as discussing the use of 'time-out' is more relevant in behavior management for older children. Option D is incorrect as it does not address the underlying cause of the child's behavior related to separation anxiety.

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