A patient presents with sudden-onset, painless vision loss in the right eye. Fundoscopic examination reveals a cherry-red spot at the macula and attenuated retinal vessels. Which of the following conditions is most likely responsible for this presentation?

Correct Answer: A

Rationale: The patient's presentation of sudden-onset, painless vision loss in the right eye, along with a cherry-red spot at the macula and attenuated retinal vessels, is classic for central retinal artery occlusion (CRAO). In CRAO, there is a sudden blockage of the central retinal artery, leading to ischemia of the retina. The cherry-red spot represents the preserved choroid blood flow against the ischemic retina. The attenuated retinal vessels are a result of decreased blood flow in the retinal circulation. This condition is considered an ophthalmic emergency and requires immediate evaluation and management to prevent permanent vision loss.

Correct Answer: A

Rationale: A woman experiencing irregular and ineffective uterine contractions with prolonged cervical dilation may indicate labor dystocia, also known as abnormal labor progression. To address this issue, the nursing intervention that should be implemented is to encourage the mother to ambulate and change positions frequently. This can help optimize fetal positioning and encourage descent through the birth canal by using gravity to aid in the progression of labor. Changing positions can also potentially improve the quality and effectiveness of contractions, leading to more successful cervical dilation and labor progress. Encouraging ambulation and position changes are non-invasive, patient-centered interventions that can be helpful in managing labor dystocia before considering more invasive interventions like cesarean section.

Correct Answer: C

Rationale: The presentation described with a sensation of fullness and pressure in the left ear, along with hearing loss and occasional tinnitus, and the findings of a retracted tympanic membrane with decreased mobility on pneumatic otoscopy are most consistent with serous otitis media, also known as otitis media with effusion (OME). OME is characterized by the presence of non-infected fluid in the middle ear space, leading to symptoms such as ear fullness, hearing loss, and occasionally tinnitus.

Correct Answer: D

Rationale: Filipinos have generally low awareness about osteoporosis. Despite the increasing number of cases in the country, many Filipinos still lack knowledge about the disease and its risk factors. Osteoporosis is a significant health concern in the Philippines, especially among the elderly population, but there is still a need for more education and awareness campaigns to improve prevention and management strategies.

Correct Answer: B

Rationale: Medical records are typically required to be retained for a certain period of time as mandated by legal and regulatory requirements. The retention period for medical records is generally between 5 to 10 years, depending on the jurisdiction and specific regulations governing healthcare facilities. Keeping medical records for this duration ensures that they are available for reference, audits, legal purposes, and continuity of care for patients. Storing medical records for an adequate length of time also helps in ensuring continuity of care and tracking patients' medical history over time, which is crucial for quality healthcare delivery. Therefore, storing charts in the Medical Records or storage room for at least 5-10 years aligns with standard practices in healthcare compliance and patient care.

Correct Answer: A

Rationale: Assessing the infant's latch and feeding effectiveness should be prioritized as the initial nursing intervention to address the client's concerns about inadequate milk supply. Poor latch can lead to ineffective milk removal, which may result in decreased milk production. By ensuring the infant is latching correctly and effectively transferring milk, the client's milk supply can be optimized. Education about techniques to increase milk production can be provided following the assessment of feeding effectiveness. Referring to a lactation consultant may be necessary for further evaluation and support if issues persist despite correcting the latch. Supplemental formula feedings should be recommended as a last resort after all other interventions have been attempted and if there are concerns about inadequate nutrition for the infant.

Correct Answer: B

Rationale: Accurate assessment and intervention by the nurse or helping person are critical factors for successful integration of loss during the grieving process. This involves the nurse's ability to assess the patient's grieving process effectively, identify their needs, provide appropriate support, and intervene when necessary. By utilizing proper assessment techniques and offering timely interventions, the nurse helps facilitate the patient's journey through the grieving process, promoting healthy coping mechanisms and ultimately assisting in achieving successful integration of their loss. Trustworthiness and a healthy attitude about grief are important qualities for a nurse, but without accurate assessment and intervention, the grieving process may not progress smoothly.

Correct Answer: C

Rationale: When assessing and managing distress in a patient with advanced dementia who is no longer able to communicate verbally, the palliative nurse should consider exploring non-verbal cues and behaviors to identify the underlying causes of distress. Since the patient cannot communicate through words, it is essential to pay close attention to their non-verbal cues such as facial expressions, body language, and changes in behavior. Distress in dementia patients can be caused by a variety of factors including physical discomfort, unmet needs, environmental stressors, emotional distress, or even medication side effects. By carefully observing and interpreting non-verbal cues, the nurse can gain insight into what might be causing the patient's distress and tailor interventions accordingly. Simply focusing on physical comfort measures may not address the root cause of the distress, and administering sedative medications without understanding the underlying cause is not considered best practice in palliative care for dementia patients.

Correct Answer: B

Rationale: When a woman in active labor is receiving intravenous oxytocin for labor augmentation, it is essential to increase the oxytocin infusion rate gradually to prevent oxytocin-induced uterine hyperstimulation. Uterine hyperstimulation can lead to complications such as fetal distress, uterine rupture, and postpartum hemorrhage. By increasing the oxytocin infusion rate gradually, the uterus has more time to adapt to the medication and reduces the risk of hyperstimulation. It is crucial for the healthcare provider to carefully monitor the woman's response to oxytocin and adjust the infusion rate as needed to ensure safe and effective labor augmentation. Monitoring for signs of uterine hyperstimulation, such as persistent contractions close together or excessive uterine activity, is crucial in preventing complications and ensuring the well-being of both the mother and baby.