Nursing Elites

1. Which of the following patients should the home care nurse assess first?

• A. A 65-year-old male with known COPD and difficulty breathing after climbing a flight of stairs.
• B. A 78-year-old with CHF who has gained 4 lbs according to her tele-monitoring.
• C. A 50-year-old with bilateral leg swelling and difficulty walking.
• D. A 60-year-old with lower back pain.

Correct answer: A

Rationale: The correct answer is A. A patient with known COPD and difficulty breathing after physical exertion like climbing stairs requires immediate assessment by the nurse. This could indicate a potential exacerbation of COPD, which needs prompt intervention to prevent respiratory distress. Choices B, C, and D describe important patient situations that also require attention, but the urgency is higher with a COPD patient experiencing difficulty breathing.

2. When admitting a client with Parkinson's disease to the home healthcare service, which nursing diagnosis should have priority in planning care?

• A. Impaired physical mobility related to muscle rigidity and weakness.
• B. Ineffective coping related to depression and dysfunction due to disease progression.
• C. Ineffective breathing pattern related to respiratory muscle weakness.
• D. Fear related to constant possibility of experiencing seizures.

Correct answer: A

Rationale: The correct answer is A: 'Impaired physical mobility related to muscle rigidity and weakness.' For a client with Parkinson's disease, impaired physical mobility is a priority nursing diagnosis because of the characteristic motor symptoms such as muscle rigidity, bradykinesia, and postural instability. Addressing impaired physical mobility is crucial to enhance the client's quality of life. Choices B, C, and D are not the priority nursing diagnoses for a client with Parkinson's disease. Ineffective coping (Choice B) and fear of seizures (Choice D) may be concerns but are not the priority. Ineffective breathing pattern (Choice C) is not typically associated with Parkinson's disease.

3. The nurse is assessing a 12-year-old who has Hemophilia A. Which finding would the nurse anticipate?

• A. An excess of red blood cells
• B. An excess of white blood cells
• C. A deficiency of clotting factor VIII
• D. A deficiency of clotting factors VIII and IX

Correct answer: C

Rationale: The correct answer is C: A deficiency of clotting factor VIII. Hemophilia A is characterized by a lack of clotting factor VIII, which is crucial for blood clotting. This deficiency results in prolonged bleeding. Choices A, B, and D are incorrect. There is no association between Hemophilia A and an excess of red blood cells (Choice A) or an excess of white blood cells (Choice B). Additionally, Hemophilia A specifically involves a deficiency of clotting factor VIII, not both factors VIII and IX (Choice D).

4. A client is admitted with the diagnosis of myocardial infarction (MI). Which of the following lab values would be consistent with this diagnosis?

• A. Low serum albumin
• B. High serum cholesterol
• C. Abnormally low white blood cell count
• D. Elevated creatinine phosphokinase (CPK)

Correct answer: D

Rationale: The correct answer is D: Elevated creatinine phosphokinase (CPK). Elevated CPK levels indicate muscle damage, including damage to the cardiac muscle, which aligns with the diagnosis of myocardial infarction. Choice A, low serum albumin, is not directly related to myocardial infarction. Choice B, high serum cholesterol, is more associated with conditions like atherosclerosis rather than acute myocardial infarction. Choice C, abnormally low white blood cell count, is typically not a lab value associated with myocardial infarction; instead, it could suggest other conditions like infections or bone marrow issues.

5. Joseph, 45 years of age, a community resident of Barangay 22-A, suddenly had 2 bouts of soft to almost watery stools after having taken his lunch. While observing his condition further at home and later deciding whether to refer him for medical treatment, you recommended that he boil a decoction for 15 minutes at low fire using 10-15 leaves of which medicinal plant?

• A. Bayabas
• B. Pancit pacitan
• C. Sambong
• D. Lagundi

Correct answer: A

Rationale: The correct answer is Bayabas (guava) leaves. Guava leaves are known for their anti-diarrheal properties, which can help alleviate Joseph's condition. Pancit pacitan, Sambong, and Lagundi are not commonly used for treating diarrhea and do not possess the same anti-diarrheal properties as guava leaves.

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