Situation 1: The knowledge of ethical and legal responsibilities in the practice
of professional nursing is important. The following questions apply. 1. As a nurse, you should know the scope of professional nursing practice. Which of the following professionals is encroaching on professional nursing practice A. A physician who administers a parenteral medication !. A medical technologist who administers dobutamine before a cardiac stress test ". A teacher who conducts lecture on health and nutrition #. A lawyer who acts as an ad$ocate for a client whose rights are $iolated %. &r. !rown, a '%(year(old American who is on short stay in the )hilippines was brought to *+ unconscious. ,n admission, his son presented a li$ing will. The nurse knows that which of the following should be done A. The lawyer or administrator of &r. !rown needs to be called since the li$ing will is not the concern of health care workers. !. #isregard the li$ing will because &r. !rown is in an emergency situation. ". -onor the li$ing will e$en if &r. !rown is an American #. *nsure the $alidity of the li$ing will by referring the issue to the American *mbassy. .. /inda, an American +0, who completed an Associate #egree in 0ursing )rogram in the 1S, has decided to 2oin her 3ilipino husband in the )hilippines. To practice her profession, /inda is seeking licensure in the )hilippines. Which of the following will be required of /inda A. 0othing because /inda may be registered in the )hilippines by mere endorsement !. "omplete a !S 0ursing degree ". Take an oath of allegiance to the )hilippines #. Acquire 3ilipino citi4enship first 5. A policy of the hospital where you work $iolates patient6s rights. What would be your appropriate action A. 7uestion policy through proper channels but respect the patient6s right when faced with the situation calling for it !. 3ollow the hospital policy. There6s no )atient6s !ill of +ights in the )hilippines ". "all the police and blotter the incident #. +esign from the hospital because this is incompatible with the professional standards set by the "ode of *thics for 3ilipino 0urses 8. 9ou admitted 0ena, : years old, at the *+ with bruises, hematoma and multiple fractures. When asked what happened, 0ena was silent and withdrawn. 9ou suspect child abuse. What would be your best course of action if you want to protect the rights of 0ena A. "all the police, blotter the incident and refer the matter to social ser$ices !. )roceed to inter$ene medically and ne$er mind the cause of the in2uries ". "all up the hospital6s legal counsel immediately #. Apply for court guardianship Situation %: 9ou are now in the entry phase of community organi4ing process after establishing rapport with the people of !arangay /aging -anda. ;. With the community health acti$ities started during the entry phase, which of these acti$ities should not be included A. "ore group formation !. "onduct of deepening social in$estigation ". )ro2ect management #. <nformation campaign on health programs '. <dentification of potential leaders is crucial during the entry phase. Which of the characteristics may not be necessary to an efficient and effecti$e community leader A. &ust ha$e relati$ely good communication !. A college graduate with management skills ". +esponsi$e and willing to work for change #. A respected member of the community :. The best techniques in identifying potential leaders in the community pro$en to be effecti$e is to A. Ask community residents to directly name persons whom they consider as community leaders !. Ask $olunteers who are willing to become community leaders ". +e$iew family background, properties and academic records of community residents #. ,bser$e people who are acti$e in small mobili4ation acti$ities that moti$ate residents to start working =. The core group is composed of indi$iduals in the community who possess the leadership potentials organi4ed into a cohesi$e working unit. The core group works with the team in A. Setting(up community organi4ation that will ser$e the interest of a sector in the community !. &obili4ing the community to act on their most immediate felt needs and participate in the deli$ery of essential health ser$ices ". &onitoring the performance of the barangay #. Selecting community acti$ities according to their preferences 1>. The nurse as a community health practitioner functions as a community A. *$aluator !. )lanner ". /eader #. 3acilitator Situation .: "ommunity health nursing practice in the )hilippines is a challenging area of nursing practice. As a result of the global financial crisis, some authorities are led to think this arena may well be e?plored for strengthening application in countries most affected. 11. 9ou are at the +-1 clinic when mother brought in her infant @un2un for his ,)A immuni4ation. 9ou ha$e assesses that the infant has diarrhea. What will be your ne?t action A. 0otify the physician !. Bi$e the ,)A ". +efer immediately #. #o not gi$e the ,)A 1%. After assessing @un2un, your nursing diagnosis is dehydration secondary to diarrhea. ,+S was administered. Which health instruction regarding ,+S therapy will you gi$e the mother once the diarrhea has stopped A. <ncrease the administration of ,+S !. +eturn to the clinic ". Stop the administration of ,+S #. #ecrease the administration of ,+S 1.. Which of the following is not true about home care for all sick infants A. !lood in the stool is a danger sign that needs to be reported !. !ring the infant to the clinic if he shows signs of difficulty of breathing ". !reastfeed frequently, day and night, during sickness and health #. &ake sure the young infant stays cool at all times 15. Aitamins help fight $arious deficiencies which affect the eye. As a health care pro$ider, you are aware that one of the following is a sign of $itamin A deficiency: A. "orneal clouding !. 3atigue ". Chalo signsD #. ,paque lens 18. "ora4on brought her child to the clinic for palmar pallor suggesti$e of anemia. The doctor prescribed iron medication and it was only the . rd day of taking such medication. 9our ne?t action would be to: A. Bi$e iron medication .? a day !. Bi$e iron and return tomorrow ". <nstruct the mother to continue gi$ing iron for 15 days #. +efer the child immediately Situation 5: <n the growth and de$elopment of any child you are fully aware that your responsibility for caring encompasses physical and psychologicalEemotional dimensions. 1;. A worried mother of a pre(school age child says to the nurse, C&y 5 year(old frequently touches his genitals.D Which of the following statements would be appropriate for the nurse to make A. C&asturbation is embarrassing to the parentsF scolding the child will stop the beha$ior.D !. CWhen this child masturbates, it can be unhealthy and dangerous.D ". CWhen children are angry or upset, they often masturbate.D #. C&asturbation is normal beha$ior, so pro$iding another acti$ity for the child would be appropriate.D 1'. A hospitali4ed child, *arl, 5 years old, being away from his home and normal en$ironment goes through separation an?iety. Which of the following beha$iors might indicates that *arl is in the denial stage of separation an?iety -e A. Searches for the caregi$er and waits for her to arri$e !. <gnores caregi$ers when they $isit ". 7uietly lies in the crib when no one is in the room #. "ries loudly e$en when being helped by the nurse 1:. After *arl6s discharge from the hospital, which of the following beha$iors might indicate that he is afraid of another separation -e A. )lays with siblings for long periods of time !. +equest to go $isit the nurses at the hospital ". Wakes up $ery early in the morning #. "arries a fa$orite blanket around the house 1=. When caring for )rincess, a . G year old child, who is recei$ing o?ygen in an o?ygen tent, which of the following toys or acti$ities would be best to offer A. Age(appropriate book !. A fa$orite blanket belonging to the child ". A radio playing soothing music #. !oard games the child can play with while alone %>. Tonton, a = year(old and 5 th grader, bed wets. The mother asks your ad$ice how this can be corrected. 9our most appropriate response is 1. C<t is normal for his age. #on6t scold him.D %. C/imit his fluids before sleeping.D .. CWake him up %(. hours from the time he sleeps.D 5. C-e might ha$e problems at home and school.D A. 1 and % !. . and 5 ". % and . #. 1 and 5 Situation 8: While working in the community, nurses obser$e $arious situations that require attention. %1. 0urse 0ikki was doing case finding in a barangay in the rural communities of /agonoy, "amarines Sur. -er target is to identify undocumented -ansen6s disease cases. Seeing her in uniform, a woman remarks, C9ou6re not a nursing student, are you < ha$e many chores today. )leaseHD and ignores the nurse. 0ikki6s immediate course of action would be to: A. Aisit the ne?t house so as not to waste the day6s acti$ity and return to re($isit this home after a day or two !. "ommunicate the incident to the barangay captain and get himEher to 2oin her in her ne?t $isit ". <gnore the woman6s beha$ior, turn around and simply lea$e her home #. The feelings and beha$iors manifested by the woman and get to the root causes of such beha$ior %%. A student nurse $isits Aling &ercy who immediately stated that she has Ctoo much work to do and she has been $isited and inter$iewed by student nurses almost daily.D After e?plaining the purpose of her $isit the student6s appropriate action would be to: A. Set an appointment at Aling &ercy6s con$enient time !. Select another family as a client ". Tell her clinical instructor about the problem #. Ask the barangay chairman for assistance %.. 0urse +ina intends to get ma?imum participation from the community members to get an accurate assessment of their health needs. To do this, nurse +ina collaborates with the community to do a situational analysis. This process entails the following e?cept A. Allowing people to freely e?press what they consider their health problem !. Asking people why they think the health problems e?ist ". Assisting the community to identify health situations that need change #. )ro$iding immediate solution to identified health problems %5. The community health nurse noticed that there are many out(of( school teenagers in the neighborhood who use drugs, smoke and drink alcohol. Their parents are working o$erseas and these teenagers li$e with their aging grandparents who ha$e difficulty controlling them. !efore arri$ing at a social diagnosis, the nurse should 1. #etermine if this situation results in breakdown of families %. *?plore to what e?tent the situation affects the life in the neighborhood .. #etermine what policies should be enacted to promote lifestyle changes 5. Assess how the educational le$el of the community affects its ability to cope with the problem A. 1 and . !. 1 and % ". % and 5 #. . and 5 %8. <nspired by the singing 2ail inmates, the nurse suggests to the barangay chairman that the out(of(school teenagers may be encouraged to stay Cout of troubleD by organi4ing acti$ities that will occupy their time, use up their energy and unify them. To reali4e such goalsEob2ecti$es, the nurse6s and community6s actions should proceed in which order 1. <dentify what manpower and money resources are needed to implement the program %. #esign the program that will meet goalsEob2ecti$es .. <dentify support acti$ities that will sustain the programs 5. #etermine the program6s impact on the target group A. 1, %, ., 5 !. ., %, 1, 5 ". %, 1, ., 5 #. 5, ., %, 1 Situation ;: "ommunity empowerment is an important aspect of a community health nurse. %;. To empower community members, the community nurse performs which acti$ity A. #o all the acti$ities for community members B. Step back at the beginning and gi$ing little input C. #efine the community needs for the members D. Bi$e ownership and leadership to the community %'. #escriptors of a community include: A. A community where the members are disease(free !. Seeking to make all the resources a$ailable to all members ". Ieeping the subgroups informed of changes whene$er necessary #. The leaders making decision for the community members %:. When a community health nurse works as a client ad$ocate, the nurse A. 1ses a passi$e approach in sol$ing identified problem !. Attempts to smooth problems o$er to keep the community calm ". <s asserti$e in speaking and acting on behalf of the client #. <s aggressi$e in pursuing the achie$ement of the client6s goals %=. The community health nurse leads a class on breastfeeding with a group of prenatal parents. The nurse allows the participants to ask questions, make comments, and reason out loud as feedback is gi$en. Which of the following techniques is the nurse using A. /ecture !. #emonstration ". +ole playing #. #iscussion .>. When beginning a relationship with a family on home $isit, the community health nurse A. <s accepting and listens carefully to the problems of all family members !. Allows the discussion to be open and non(directional ". 3ocuses on the problem of one of the family members #. *ncourages others to speak for the main client to get an unbiased $iew Situation ': &ichelle, %1, single college student, thinks she is pregnant. She described herself as a Cparty animalD, smokes, drinks and uses mari2uana. She said she has always been CcarefulD, she is not sure who the father is. She missed three menstrual cycles and shows abdominal enlargement. She is $ery concerned about her predicament and her situation has e?acerbated her drinking of alcohol. .1. &ichelle started drinking alcohol in high school and is used to Chard drinksD. 9ou inform her that drinking while pregnant e?poses the fetus to the possibility of ha$ing fetal alcohol syndrome J3ASK with these characteristics e?cept: A. /owered birth weight !. "ogniti$e impairments ". 3acial anomalies #. #ecreased muscle tone .%. Additional information gi$en to &ichelle about alcohol intake during pregnancy includes A. 0o safe le$el of drinking has been set during pregnancy therefore abstinence is ad$ised !. Alcohol intake is linked to increased risk of spontaneous abortion ". A woman can safely drink a glass of wine if she has heart problems to aid in circulation #. Alcohol has no known teratogenic effects on the fetus at low or high intake le$els ... &ichelle tells you, C< don6t want this pregnancy. < am not ready to raise a child alone. < want an abortion.D Which of the following is your most appropriate response to &ichelle A. CWhy don6t you get married so you can ha$e support during pregnancyD !. C9ou ha$e to ha$e a lot of faith, pray for guidance so you can make a wise choice.D ". C9ou are not ready to face the consequences of this pregnancyD #. CAll you ha$e to do is stop drinking, is that difficult for youD .5. &ichelle continues to smoke 1(% sticks of mari2uana when with friends. 9ou ad$ice her to refrain from smoking mari2uana because it A. <ncrease risk for cerebral abnormalities of the fetus !. <ncrease risk of sudden infant death syndrome ". -as strong e$idence of teratogenic effects on the fetus #. <mpairs her coordination and critical thinking that puts her at risk .8. When taking care of &ichelle who smokes, your inter$ention should focus on: risk for fetal in2ury resulting from maternal smoking. 9ou inform &ichelle about the ha4ards of smoking which include: 1. -igh incidence of premature birth %. <ncreased incidence of sudden infant death syndrome .. 5. /ow birth weight A. 1, % and 5 !. 1, %, . and 5 ". 1, . and 5 #. %, . and 5 Situation :: -ealth education among pregnant women is important .;. An understanding of physiologic adaptations to pregnancy is important. The following changes in pregnancy are important to keep in mind in order to address client6s needs e?cept A. "ardiac output increased by %8L to 8>L during pregnancy !. The temperature decrease slightly early in pregnancy ". The anterior pituitary gland secretes o?ytocin late in pregnancy #. The circulating fibrinogen le$el decreased as much as 8>L during pregnancy .'. Which statement by a client indicates that the teaching about nausea and $omiting of pregnancy needs to be done by the nurse A. C< need to drink an e?tra glass of water with e$ery mealD !. C< will ask my husband not to wear aftersha$e because it upsets my stomachD ". C< will try to eat 8 or ; smaller meals during the dayD #. C< hope that taking a nap when < got home from work makes me feel betterD .:. Amanda is now 1; weeks pregnant. <f the pregnancy is progressing as e?pected, where would the practitioner find the uterine fundus A. -alfway between the pubic bone and the umbilicus !. The uterine fundus would not be palpable at 1; weeks ". At the umbilicus #. @ust abo$e the pubic bone .=. 9ou are teaching Amanda about proper diet during pregnancy. <f Amanda understands your instructions, how will she reply when you ask her appro?imately how many more calories per day she needs now that she is pregnant A. CAppro?imately 8>> caloriesD !. C< should not increase my calories while <6m pregnantD ". CAbout .>> caloriesD #. C< need to double my calories because <6m eating for twoD 5>. A 1'(year(old primigra$ida client at appro?imately 18 weeks gestation is to undergo alpha(fetoprotein JA3)K screening. When de$eloping the teaching plan for this client, the nurse should include which of the followingM A. !. +esults are usually $ery accurate until %> weeks gestation ". <ncreased le$els of A3) are associated with neural tube defects #. 1ltrasonography usually accompanies A3) testing Situation =: 3amilyE-ome -ealth 0ursing has currently become a significant area of nursing. "ommunity health nurse Anna is taking care of different clients in her caseload. 51. Anna has been caring for a child in the home. She has a tracheostomy tube and is o?ygen N dependent. Anna prefers to do the care early in the morning due to a hea$y caseload. The family requests that care be done when the child is awake by 1> am. The best response by Anna would be A. C< will see if < can find another nurse who can meet your preferred schedule.D !. C<6ll gi$e care at 1> am, other children needing my care may not be attended to.D ". C<6m sorry < wish < could, but < cannot do so due to hea$y workload.D #. C/et6s look at what time is in the child6s best interest and then we can work out a better schedule.D 5%. Anna best e?emplifies primary pre$ention by which of the following acti$ities A. Teaching new mothers infant care !. <nfant phototherapy ". ,?ygen humidification #. Tracheostomy care 5.. Which of Anna6s teaching acti$ities would be considered primary pre$ention when caring for clients in her case load A. )ro$iding families with her telephone number for any home emergencies !. *ducating parents on the importance of routine immuni4ation ". Teaching first aid for insect bites #. *ducating parents on the signs of lead poisoning 55. Anna finds that a toddler has some de$elopmental delays during a home $isit. When looking for a cause of contributing factor, which of the following en$ironmental factors would she consider most important to assess A. #ust mites in child6s toys !. /ead paint in the crib ". -ouse pets #. )resence of asbestos in the home 58. Anna6s functions include acti$ities for secondary pre$ention. <n a family, the health profile re$eals diabetes in the father of the family. A classic demonstration of secondary pre$ention would be A. Teaching the diabetic client about foot care !. Assisting the diabetic client in his daily insulin in2ections ". -elping the client obtain a glucometer for accurate monitoring of blood sugar #. <nforming the client how to maintain -b A1c $alue at 8.8 or less Situation 1>: )romotion of safe motherhood in $aried clinical settings is consistent with safety and quality concerns of e$ery nurse in the care of women during normal pregnancy. 5;. 0urse @ulie is taking care of a pregnant client whose last day of menstrual period was @une %%, %>1>. 1sing the 0agele6s rule, the estimated date of birth would be A. &arch 18, %>11 !. April %=, %>11 ". &arch %=, %>11 #. April 15, %>11 5'. 0urse @ulie attends to another pregnant client who has % children. -er history re$eals that her first pregnancy ended in stillbirth at .% weeks of gestation, her second pregnancy with the birth of her daughter at .8 weeks, and her third pregnancy with the birth of her son at 51 weeks. 1sing the B) T)A/& format, 0urse @ulie would record the woman6s current obstetrical history as A. B.). JT1 )1 A1 /. &>K !. B5). JT1 )% /% &>K ". B5)5 JT% )1 A> /1 &>K #. B.). JT1 )% A> /1 &>K 5:. A %>(year(old client $isits @ulie at her 0ursing )renatal "linic because she suspects that she is pregnant. She tells the nurse that she missed one menstrual period and that she e?perienced nausea and $omiting, urinary frequency and fatigue. !ased on her assessment, 0urse @ulie suspects that her client has signs of pregnancy categori4ed as which of the following A. )resumpti$e !. )redicti$e ". )robable #. )ositi$e 5=. While doing /eopold6s maneu$er on a client, 0urse @ulie notes the presence of a firm round prominence o$er the symphysis pubis, a smooth con$e? structure down her right side, an irregular lump down on her left side, and soft roundness in the fundus. The nurse should conclude that the fetal position is A. /,A Jleft occiput anteriorK !. /,) Jleft occiput posteriorK ". +SA Jright shoulder anteriorK #. +,) Jright occiput posteriorK 8>. When performing /eopold6s maneu$er to a primigra$ida client, the nurse is aware that to make her more comfortable during the procedureF she should prepare the client by asking her to A. *mpty her bladder prior to the procedure !. /ie on her left side drug during the procedure ". A$oid eating immediately before the procedure #. -yper$entilate for a short time before beginning the procedure 81. A .(year(old child weighing, 15 kgs. has anemia with some pallor and needs iron and mebenda4ole pre$iously. As the nurse you should gi$e the child iron folate and mebenda4ole in what dosage A. '.8 ml or 1 tsp daily for 15 days and mebenda4ole 8>> mg single dose !. 1> cc or % tsp daily for .> days and mebenda4ole 8>> mg single dose ". 1> cc or % tsp daily for .> days and mebenda4ole %8> mg single dose #. 8 ml or 1 tsp daily for 15 days and mebenda4ole 8>> mg single dose 8%. Aitamin A is gi$en to the child with measles because it A. +esists the $iral infection in the eyes, cell layers in the lungs, gastrointestinal tract, mouth and throat !. +einforces the body6s immune system ". <s needed for supplementation #. -elps the immune system pre$ent other infections 8.. <n gi$ing chloroquine you should A. -ea$ily guard the client !. *?plain to the mother that she should watch her child carefully for .> minutes after gi$ing the medicine ". *?plain to the mother that it should be gi$en for % days only #. <nstruct the mother to gi$e the first dose at home 85. The child6s symptoms are under the classification of se$ere dengue hemorrhagic fe$er of the <&"< strategy. Which of the following treatments should be done immediately A. ,bser$e the client at the health center and refer urgently if the condition worsens !. Bi$e fluids or ,+S and refer urgently to the hospital ". <mmuni4e the child before referral #. Bi$e the first dose of the appropriate antibiotics and refer urgently to the hospital 88. A child needs urgent referral for mastoiditis. The following is a list of treatments for all ear problems in <&"< classification. Which among these pre(referral treatments should not be included A. Bi$e the child appropriate antibiotics for 8 days !. #o not gi$e any medications ". Bi$e the child first dose of antibiotics #. Bi$e the first dose of paracetamol for pain Situation 1%: Among the nurse6s responsibility after deli$ery is the pro$ision of safe physical, emotional, and psychological support for the mother6s well( being. 8;. What nursing inter$ention would be most helpful in pro$iding emotional support to /ydia and her family after a cesarian deli$ery A. +ecommending frequent rest periods for the new mother !. *ncouraging the father to obser$e the infant6s first bath ". )ro$iding opportunities to discuss reaction to the birth e?perience #. )ositioning the infant with pillows during feeding 8'. The nurse assesses /ydia after deli$ery. What data suggests that /ydia is at increased risk for hemorrhage A. -istory of gestational diabetes !. <nfant birth weight of ' lbs 11 o4 J.5': gK ". : hours length of labor #. Bra$ida ' )ara 8 8:. Another postpartum woman had post(partum bleeding. Which areas would the nurse need to assess before the client ambulates A. Attachment, lochia color, complete blood cell count !. -eight, le$el of orientation, support system ". #egree of responsi$eness, respiratory rate, fundus location #. !lood pressure, pulse, complaints of di44iness 8=. When assessing another client who ga$e birth 5 hours ago, the nurse finds the uterus to be firm, % fingerbreadths abo$e the umbilicus, and displaced to the right. /ochia rubra is moderate. What would be the first nursing action A. Bently massage the fundus !. <nsert a foley catheter ". *ncourage the woman to urinate #. +ecord these as normal findings ;>. When assessing a client 15 hours postpartum, the following data are collected: T N .:.1O", pulse 1>5, respirations 1=, blood pressure 11:E'%. What would be the best nursing action A. &assage the uterus and e?press clots !. Assess for uterine tenderness and odor of lochia ". *ncourage the client to increase her fluid intake #. +eport these findings to the health care pro$ider Situation 1.: <n the care of pregnant women, the nurse is always mindful of her quality and safety responsibilities for both mother and her unborn child. ;1. A client who is 1> weeks pregnant calls the clinic complaining of morning sickness. <n order to promote relief, the nurse6s best suggestion is for the client to A. <ncrease her fat intake before bedtime !. #rink more high(calorie fluids with her meals ". *at dry crackers before arising #. -a$e % small meals daily and snack at noon ;%. Another client who is on her 1 st trimester of pregnancy complains of heartburn. The most appropriate inter$ention to reli$e this condition is to A. *at small frequent meals !. /ie down after eating ". ,mit fluid while eating #. *?ercise before eating ;.. As pregnancy progresses and the date of deli$ery draws near, the nurse constantly monitors the child6s position in the womb of her mother. The nurse is aware that the most fa$orable fetal position for birth is A. )osterior position of the fetal head !. Trans$erse lie ". Aerte? position #. 3rank breech presentation ;5. A client who is .8 weeks pregnant arri$es at the labor and deli$ery unit with leaking clear $aginal fluid. Which of the following inter$entions is the most appropriate for the nurse to take A. ,btain a catheteri4ed urine specimen !. *ncourage the client to ambulate ". )erform $aginal e?amination #. ,btain a sterile sample of the fluid ;8. The nurse recei$es a client, 5% weeks gestation, . cm dilated with ..L effacement, membranes intact, and the fetus is at P% station. The fetal heart rate is 15> N 18> beats per minute. Two hours later, the nurse recogni4es that for the past 1> minutes, the 3-+ ranged from 1;> N 1=> bpm, uterine contractions ha$e been strong occurring between . N 5 mintues and lasting 5> N ;> seconds. The client uttered, C&y baby has been e?tremely acti$e.D The nurse should be concerned about which symptom that is indicati$e of fetal hypo?ia A. Abnormally long uterine contractions !. *?cessi$e fetal acti$ity and fetal tachycardia ". *?cessi$e frequent contractions with rapid fetal mo$ement #. Abnormally strong uterine intensity Situation 15: &anagement of resources and en$ironment includes e$ery potential and e?isting resources which the nurse can utili4e to promote and maintain health, pre$ent illness, and assist in the task of cure and rehabilitation. The <&"< chart prescribed by the World -ealth ,rgani4ation is one such resource. ;;. The <&"< chart pro$ides the necessary procedure when identifying the appropriate inter$entions to be done. -owe$er, the community health nurse should be aware that the following factor should be considered in utili4ing the case management chart: A. Age of the child !. #anger signs ". "hief complaint #. )roblem of the child ;'. <n the <&"< classification tables, the color yellow indicates that a A. "hild needs an appropriate antibiotic or other treatment !. "hild does not need specific medical treatment ". +eferral or admission is needed #. "hief complaint needs an urgent attention ;:. 1pon assessment, the nurse notes that a child has fe$er. <n the presence of mosquito bites, the nurse would suspect the following illnesses e?cept A. &easles !. &alaria ". -emorrhagic fe$er #. #-3 ;=. All of the following illnesses are caused by a $irus e?cept A. &easles !. &alaria ". -(fe$er #. )arotitis '>. Which of the following laboratory tests would classify the presence of fe$er as positi$e for malaria A. Tourniquet !. ,ccult blood ". "!" #. !lood smear Situation 18: Iarina, 8 months old, weighs 8.% kilograms as a temperature of .:O". She is brought to the health center. -er mother says she is not eating well, feels hot to touch, able to drink, not $omiting, no con$ulsions and not lethargic, and not coughing. They li$e in a malaria(risk area. -er fe$er started % days ago. She has no signs of measles, no stiff neck or runny nose. '1. -ow will you classify Iarina6s illness A. )ain fe$er !. Se$ere febrile disease ". &alaria #. 3e$er, no malaria '%. The following treatments are appropriate for Iarina e?cept A. 3ollow(up in % days !. Bi$e oral anti(malaria drugs ". Ad$ise when to return immediately #. Bi$e 1 dose of paracetamol for temperature of .'.8O" '.. A child should be checked for capillary refill if A. The child has petechiae !. The child6s e?tremities feel warm ". There is fe$er for more than ' days #. The e?tremity feels cold '5. <f the capillary refill takes more than . seconds, it may mean that the child is in A. Se$ere febrile disease !. "irculatory failure ". Shock #. #ehydrated state '8. A child li$ing in a non(malaria risk area who has stiff neck may be classified as ha$ing A. &alaria !. Se$ere febrile disease ". +E, &alaria #. 3e$er, no malaria Situation 1;: "ommunity health nurses take care of clients with $arying health conditions. ';. A population group that should be gi$en attention by the community health nurse is obese women who become pregnant. ,besity is responsible for what complications during pregnancy A. )rematurity !. Anemia ". Bestational diabetes #. Spontaneous abortion ''. A community health nurse $isits a child with e?acerbation of asthma. The nurse would most likely assess for which one of the following in determining what e?acerbates the child6s asthma A. The educational le$el of the child6s caregi$er !. The child6s height and weight ". The amount of e?clusion the child is e?periencing #. Air pollution and second(hand cigarette smoke ':. Which of the following best describes an ad$anced practice nurse A. An +0 who assists the physician during a cesarian section deli$ery !. An +0 who works in the high(risk newborn nursery ". A master6s prepared +0 who is a manager of a large labor and deli$ery unit #. A certified +0 who pro$ides primary care to low(risk clients in a community health center '=. The four ma2or change agents that impact the future of community health care for children and families are demographics, science and A. The amount of influence the public has on legislator and the political party in power !. The stock market and recession periods ". -ospital administrati$e policies and health care reimbursement #. &arket(dri$en economic policy and technology :>. A home health nurse is made aware that a client and family are about to lose their home due to foreclosure. The nurse contacts the social ser$ice department of the home health care agency for assistance in finding housing for the family. The actions taken by the nurse best e?emplifies which of the following roles of the community health care nurse A. "linician !. "onsultant ". Ad$ocate #. +esearcher Situation 1': "arol is 18 months old, weighs :.8 kgs, is not eating well and is unable to breastfeed. She is not $omiting, has no con$ulsion and not abnormally sleepy or difficult to awaken. -er temperature is .:.8O". 1se the <&"< strategy for this situation. :1. <f you were the nurse in charge of "arol, how will you classify her illness A. A child with a general danger sign !. Aery se$ere febrile disease ". Se$ere pneumonia #. Se$ere malnutrition :%. Which of the following is considered as a general danger sign in the case of "arol A. 0o $omiting !. -as no con$ulsion ". Temperature of .:.8O" #. 1nable to breastfeed :.. Which of the following is not considered as a general danger sign A. Aomits e$erything !. 1nable to drink or breastfeed ". -as had con$ulsion #. 3ast breathing :5. Which of the following steps is not included in the <&"< strategy A. <dentify treatment !. "ounsel and follow(up ". +eferral #. Assess and classify :8. Which of the following should not be included in deciding that Cthe child $omits e$erythingD A. "hild e?periences occasional $omiting !. When offered fluids, may not be able to drink ". &aybe too weak to drink and eat at all #. "hild is not able to keep anything down at all Situation 1:: The nurse is taking care of clients who are in their % nd and . rd
trimester of pregnancy. :;. Amor, .8 years old and .; weeks pregnant, B1 )>, goes to the hospital reporting a feeling of Cwanting to pushD, lower back pains, abdominal cramps, and passage of mucous with some blood. With the presenting symptoms of the client, the nurse suspects that the client is ha$ing A. Abruption placenta !. )reterm labor ". Spontaneous abortion #. Threatened abortion :'. Amor6s bag of waters ruptures spontaneously and she deli$ers the baby within the hour after the premature rupture of membranes J)+,&K. The nurse should watch out for the most immediate danger to the fetus: 1. <nfection during the intra and postpartum periods %. <nfant respiratory distress syndrome .. 1mbilical cord compression 5. 3etal abnormality A. 1 and 5 !. % and . ". % and 5 #. 1 and . ::. &anagement of clients with premature rupture of membranes during the early stages of pregnancy without laborEdeli$ery includes the use of maternal antibiotics. After the premature rupture of membranes, the nurse should closely obser$e the client. The immediate nursing action would be to A. Teach the client breast stimulation !. +eport presence of uterine contractions ". Take the client6s $ital signs and 3-+ e$ery 5 hours and report significant changes #. +eport foul or strong odor with yellowish color of $aginal discharge :=. /ower back pain in pregnant women is caused by the body6s attempt to balance as the uterus enlarges. To help reduce the lower back pain of a client who is in her ; th month of pregnancy, the nurse ad$ises her to A. Walk long distance until she feels out of breathe !. *le$ate her feet ". #o pel$ic rocking #. #o Iegel6s e?ercise =>. Allison is ' months pregnant, B%)1, 5% years old and is e?pecting twin girl. She has shown symptoms of mild pregnancy(induced hypertension with a blood pressure of 15>E=> mm-g and protein in her urine tests. An appropriate nursing action would be to gi$e Allison important health information while she is managed at home. The nurse tells Allison to A. -a$e frequent bed rest on left side(lying position to facilitate placental and renal blood flow !. )erform mild .> minute e?ercise daily ". *liminate sodium from the diet #. +egularly monitor her pulse rate Situation 1=: Total 7uality &anagement JT7&K and "ontinuous 7uality <mpro$ement J"7<K are considered sound tools in the management of organi4ations, groups, agencies in $arious care settings where professional nurses are in$ol$ed. =1. A nurse manager understands that the de$elopment of T7& and "7< are meant to A. Ser$e as a system of e?ternal measures and balance !. )rotect patients and families during a health care crisis ". Assure society that cost containment would not compromise safety #. +esult in e?tensi$e statistical bases needed to pro$ide patient care =%. Which of these does not belong as a general principle of total quality management A. <mpro$ing the quality of ser$ice is a continuous process !. 3ocusing on the work process de$elops impro$ement opportunities ". 7uality is achie$ed by the participation of e$eryone #. #ecisions to impro$e or change a process are based on the ma2ority rule =.. Which of the following are e?amples of structure standards that are critical to the success of different public health programs 1. "old chain in *?panded )rogram on <mmuni4ation J*)<K %. *ssential #rugs in &aternal "are -ealth J&"-K .. 0ursing care of patients with Acute +espiratory <nfections 5. T! "ontrol )rogram &anagement A. 1 and % !. All e?cept . ". . and 5 #. All of the abo$e =5. ,ne of the ma2or challenges in nursing management is the pro$ision of an en$ironment that is conduci$e to legal and ethical practice. Which of the following is not considered part of ethical nursing practice A. )ro$iding care to clients regardless of social class and political beliefs !. &aintaining confidentiality of information ". !eha$ing in a manner that is consistent with $alues, professional code of ethics and norms of community #. Working in accordance with the nursing law and other related laws affecting nursing practice =8. To ensure the pro$ision of safe and quality nursing care, clinical practice guidelines ha$e been de$eloped. Which of the following is not an e?ample of clinical practice guidelines A. )rotocol !. "linical pathways ". +esearch e?pectations #. Algorithms Situation %>: 9ou are conducting a mother6s class at the barangay health station and the participants are in $arying periods of pregnancy. After the class session, the mothers started asking more information from you. =;. +hoda asks you why she could not feel fetal mo$ements all the time. 9our most appropriate response is that fetal mo$ements A. #ecrease as the mother nears her term !. <ncrease if the mother drinks alcohol ". #ecreases as the mother6s acti$ity decreases #. Are usually not present during the fetal sleep cycle ='. At .; weeks gestation, 0ina tells the nurse that she has been e?periencing shortness of breath. Which of the following suggestions would be most helpful A. *mpty bladder regularly !. Sleep with e?tra pillows ". Warm shower before sleeping #. A$oid gas forming foods =:. "ynthia, %5 weeks pregnant, tells the nurse that she is bothered by pruritus. Which of the following would you suggest A. #o deep breathing e?ercises !. Apply anti(pruritus ointment ". #rink si? glasses of water a day #. +egular tepid bath then apply lotion ==. &yra states that she is uncomfortable with her e?perience of flatulence, bloating, and belching now that she is %: weeks of gestation. What would be your most appropriate suggestion A. #ecrease intake of fluids !. *at small and frequent meals ". "hew food slowly #. &aintain regular bowel habits 1>>. 0orie complains of leg cramps especially after reclining. She is now on her .; th week of gestation. Which of the following instructions will help the client when she has leg cramps A. Stand and lean forward dorsifle?ing foot of affected leg !. -a$e another person antefle? the foot of the affected leg and e?tend the knee ". Stand and fle? the affected leg #. Sit and hypere?tend the affected leg