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 presentation described with sudden-onset, painless vision loss, a cherry-red spot at the macula, and attenuated retinal vessels is classic for central retinal artery occlusion (CRAO). CRAO occurs when the central retinal artery, which supplies blood to the inner retinal layers, becomes occluded. The cherry-red spot is due to the exposure of the underlying choroid, which still appears red as it is not affected by the blockage. Attenuated retinal vessels and a pale retina may also be seen due to ischemia. In contrast, central retinal vein occlusion (choice B) presents with sudden painless vision loss, retinal hemorrhages, dilated retinal veins, and cotton-wool spots. Retinal detachment (choice C) typically presents with flashes, floaters, and a curtain-like shadow across the vision. Acute angle-closure glaucoma (

Correct Answer: C

Rationale: The indicators listed indicate measures that Nurse Cirila can take to maintain a safe environment for her pediatric patients. However, assessing the competencies of staff before delegating a task is more related to ensuring effective delegation and appropriate task assignment rather than directly ensuring a safe environment for patients. While it is important to delegate tasks to qualified staff, this specific action does not directly contribute to maintaining a safe environment in the same manner as the other indicators listed (proper waste disposal, infection control, emergency protocols).

Correct Answer: C

Rationale: Placing a patient in restraints before utilizing other less restrictive interventions violates the patient's right to receive treatment in the least restrictive environment. Restraints should be used as a last resort when all other options have been exhausted, as they can be restrictive to the patient's movement and freedom. Patients have the right to be treated in a manner that minimizes limitations on their personal freedom and autonomy. Restraints should only be utilized when absolutely necessary for the safety of the patient or others.

Correct Answer: A

Rationale: Providing education on techniques to improve latch and milk transfer should be prioritized to support successful breastfeeding in this situation. Newborns who are macrosomic (large for gestational age) may have difficulties latching due to their size and may require additional support to effectively breastfeed. By educating the postpartum client on proper latch techniques and milk transfer, the nurse can help optimize the breastfeeding experience for both the mother and baby. This intervention focuses on addressing the specific concerns related to the infant's size and aims to promote successful breastfeeding despite potential challenges. As such, recommending supplemental formula feedings, encouraging the client to avoid breastfeeding, or immediately referring to a lactation consultant may not directly address the immediate need for support in improving breastfeeding in this situation.

Correct Answer: C

Rationale: The most effective strategy in preventing more incidence of dengue infection is to target the breeding places of the Aedes mosquitoes, which are the vectors responsible for transmitting the dengue virus. By eliminating stagnant water sources where these mosquitoes breed, such as uncovered containers, flower pots, and discarded tires, the mosquito population can be significantly reduced. This, in turn, helps to lower the risk of dengue transmission to humans. While healthy nutritious food, burning of leaves and garbage, and adequate rest and sleep are important for overall health and immune function, they do not directly address the primary cause of dengue transmission, which is the Aedes mosquito population.

Correct Answer: A

Rationale: Battery refers to the intentional touching of another person without consent, resulting in harm or offense. In this scenario, the nurse inserted the urinary catheter into the client's urethra without the client's consent, leading to an injury. This action constitutes battery as the nurse carried out a medical procedure without the client's permission, resulting in harm to the client. The client can sue the nurse for battery in this situation.

Correct Answer: D

Rationale: Nurse Noli should not advise patients to eat more saturated fats. Saturated fats are known to increase cholesterol levels and can lead to heart disease and other health issues. It is recommended to limit the intake of saturated fats in the diet. Therefore, advising patients to eat more saturated fats goes against the goal of promoting heart-healthy habits. Instead, Nurse Noli should focus on encouraging patients to cut down on salt intake, consume more fruits and vegetables, and eat regular meals to maintain a balanced and healthy diet.

Correct Answer: B

Rationale: Beta-blockers work by blocking the effects of adrenaline on beta receptors in the body. One common adverse effect of beta-blockers is bradycardia, or a slowed heart rate. Since the patient is being prescribed a beta-blocker for migraine headaches, it is important for the nurse to monitor closely for signs and symptoms of bradycardia such as dizziness, fatigue, and fainting. Monitoring the heart rate regularly and reporting any significant decrease to the healthcare provider is essential to prevent complications associated with bradycardia. Compared to the other options, bradycardia is the most relevant adverse effect to monitor in a patient prescribed a beta-blocker.

Correct Answer: A

Rationale: In cases of poisoning, the main goals are to inactivate the poison to prevent further harm, administer the specific antidote if available to counteract the effects of the poison, and support vital organ functions to help the patient recover. Inducing the patient to vomit (III) is not always recommended as it can potentially cause more harm, especially if the ingested substance is corrosive. Therefore, the most appropriate goals in poisoning are to inactivate the poison, administer the specific antidote, and support vital organ functions.