Nursing Elites

1. The nurse is performing a physical assessment on a client with insulin-dependent diabetes mellitus. Which client complaint calls for immediate nursing action?

• A. Diaphoresis and shakiness
• B. Reduced sensation in the lower leg
• C. Intense thirst and hunger
• D. Painful hematoma on thigh

Correct answer: A

Rationale: Diaphoresis and shakiness are classic signs of hypoglycemia in a client with insulin-dependent diabetes mellitus. Hypoglycemia is a medical emergency that requires immediate intervention to prevent further complications. The nurse should address this complaint promptly by providing a fast-acting source of glucose to raise the client's blood sugar levels. Reduced sensation in the lower leg may indicate peripheral neuropathy, which is a common complication of diabetes but does not require immediate action unless there are signs of injury. Intense thirst and hunger are symptoms of hyperglycemia, which also requires intervention but not as urgently as hypoglycemia. A painful hematoma on the thigh may require assessment and management, but it is not as urgent as addressing hypoglycemia.

2. The following statements pertain to devolution as mandated by the local government code. Which of these is not correct?

• A. People can participate in policymaking relative to healthcare delivery.
• B. Devolution will enhance the quality of community life.
• C. The barangay shall set criteria as to who shall be given priority in the delivery of healthcare services.
• D. The DOH shall transfer regulatory function of inspecting food establishments to local government units.

Correct answer: D

Rationale: The correct answer is D. The Department of Health (DOH) retains regulatory functions for inspecting food establishments, and it is not transferred to local government units. Choices A, B, and C are correct because devolution allows people to participate in policymaking for healthcare, enhances community life quality, and empowers the barangay to set criteria for healthcare service prioritization.

3. 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.

4. BCG vaccine is supplied in:

• A. freeze-dried form in a sealed glass ampule
• B. liquid form in a sealed glass ampule
• C. liquid form in a vial
• D. both 2 and 3

Correct answer: A

Rationale: The correct answer is A. BCG vaccine is commonly supplied in freeze-dried form, not in liquid form. Therefore, choices B and C are incorrect. Option D is also incorrect as the vaccine is not supplied in liquid form in a glass ampule.

5. During a large community disaster, a man states that the blast threw him out of a second-story window. Which action should the nurse implement first?

• A. Logroll the client to his side and assess for back injuries
• B. Perform a complete neurological assessment
• C. Open the client's airway immediately
• D. Place the nurse's hands around the client's neck to stabilize

Correct answer: D

Rationale: In this situation, the nurse should first stabilize the client's neck to prevent potential spinal cord injuries. Logrolling the client or performing other assessments should only be done after ensuring spinal stabilization. Opening the airway immediately is important in cases of airway obstruction, but stabilizing the neck takes priority in this scenario. Performing a complete neurological assessment may delay immediate stabilization, which is crucial in suspected spinal injuries.

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