Nursing Elites

1. When the nurse identifies what appears to be ventricular tachycardia on the cardiac monitor of a client being evaluated for possible myocardial infarction, the first action the nurse should perform is to

• A. Begin cardiopulmonary resuscitation
• B. Prepare for immediate defibrillation
• C. Notify the 'Code' team and healthcare provider
• D. Assess airway, breathing, and circulation

Correct answer: D

Rationale: The correct first action for the nurse to take when identifying what appears to be ventricular tachycardia in a client being evaluated for possible myocardial infarction is to assess the client's airway, breathing, and circulation. This step is crucial to determine the client's stability and the need for immediate intervention. Beginning cardiopulmonary resuscitation or preparing for immediate defibrillation without first assessing the airway, breathing, and circulation could delay potentially life-saving interventions. Notifying the 'Code' team and healthcare provider should come after ensuring the client's immediate needs are addressed.

2. The client with acute hypocalcemia is admitted to the unit. Nursing action should include:

• A. Implement seizure precautions
• B. Assess for hypoglycemia
• C. Monitor for visual changes
• D. Observe for muscle weakness

Correct answer: A

Rationale: The correct action for a client with acute hypocalcemia is to implement seizure precautions. Hypocalcemia can lead to tetany and seizures due to neuromuscular irritability. Assessing for hypoglycemia (choice B) is not directly related to hypocalcemia. Monitoring for visual changes (choice C) is more indicative of conditions like hyperglycemia or retinal disorders. Observing for muscle weakness (choice D) is a common symptom of hypocalcemia but does not address the immediate risk of seizures, which is why implementing seizure precautions is the priority nursing action.

3. Community Health Nursing (CHN) in the Philippines encompasses healthcare provisions affecting four clients: individuals, families, population groups, and communities. In the course of our community health work, traditional, non-traditional, alternative, or complementary health care strategies are utilized. The legal basis for this action may be derived from the:

• A. PhilHealth Act
• B. Traditional and Alternative Health Care Law
• C. Philippine Nursing Act
• D. Philippine Medical Act

Correct answer: B

Rationale: The correct answer is B: Traditional and Alternative Health Care Law. This law provides the legal basis for integrating alternative health care strategies. The PhilHealth Act (Choice A) focuses on health insurance, the Philippine Nursing Act (Choice C) regulates the nursing profession, and the Philippine Medical Act (Choice D) pertains to the medical profession. These laws are not directly related to the integration of traditional, non-traditional, alternative, or complementary health care strategies in community health work.

4. The family health care plan includes the following listed in sequence:

• A. objective, statement of the problem, intervention, and evaluation
• B. objectives, intervention, evaluation, and statement of the problem
• C. evaluation, statement of the problems, objectives, and interventions
• D. statement of the problems, objectives, intervention, and evaluation

Correct answer: D

Rationale: In a family health care plan, the correct sequence should start with identifying the problems (statement of the problems), setting objectives, planning interventions, and then evaluating the outcomes. This sequence ensures a logical and structured approach to healthcare planning. Choices A, B, and C are incorrect as they do not follow the logical order of healthcare planning steps.

5. A child is diagnosed with poison ivy. The mother tells the nurse that she does not know how her child contracted the rash since he had not been playing in wooded areas. As the nurse asks questions about possible contact, which of the following would the nurse recognize as highest risk for exposure?

• A. Playing with toys in a backyard flower garden
• B. Eating small amounts of grass while playing 'farm'
• C. Playing with cars on the pavement near burning leaves
• D. Throwing a ball to a neighborhood child who has poison ivy

Correct answer: C

Rationale: The correct answer is C. Poison ivy can be contracted through smoke from burning plants, which can carry the urushiol oil that causes the rash. Playing near burning leaves would be the highest risk for exposure in this scenario. Choices A, B, and D do not involve direct contact with burning plants or leaves, making them lower-risk activities for exposure to poison ivy.

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