A rape victim tells the emergency nurse, I feel so dirty. Help me take a shower before I get examined. The nurse should:

Correct Answer: C

Rationale: The correct response for the nurse in this situation would be to offer the victim a shower after evidence is collected. It is essential to preserve any physical evidence that may be present from the assault during the forensic examination. Allowing the victim to shower before evidence is collected could potentially compromise the evidence and hinder the investigation. The nurse should provide support to the victim during this difficult time and assure them that they will have the opportunity to shower once the necessary evidence is obtained. It is also crucial for the nurse to offer empathy and understanding while explaining the importance of preserving any evidence related to the assault.

Correct Answer: D

Rationale: When someone is bitten by a dog, the most important first aid step is to wash the wound thoroughly with running water. This helps to remove any dirt or bacteria from the wound, reducing the risk of infection. Washing the wound with garlic (choice A) is not recommended as it can irritate the skin and may not effectively clean the wound. Feeding the dog (choice B) is not relevant to treating the bite wound. Bleeding the bitten area (choice C) is also not necessary and can actually increase the risk of infection. Therefore, the best advice the nurse should give in case of a dog bite is to wash the wound thoroughly with running water.

Correct Answer: B

Rationale: Benign prostatic hyperplasia (BPH) is a condition characterized by an abnormal enlargement of the prostate gland, which is non-cancerous. This enlargement can lead to lower urinary tract symptoms such as urinary hesitancy (difficulty starting the urine stream), weak urinary stream, incomplete bladder emptying, frequent urination, urgency, and nocturia. BPH is a common condition in aging men and is not usually associated with prostate cancer. Other conditions like prostate cancer, prostatitis, and prostate adenoma may present with similar symptoms, but BPH is specifically characterized by the non-cancerous enlargement of the prostate gland. Treatment for BPH may include medications to improve symptoms or surgical procedures to reduce the size of the prostate gland.

Correct Answer: A

Rationale: When handling information about families in the community, the nurse should consider the principle of confidentiality as ethical. Confidentiality refers to the obligation of healthcare providers to safeguard the privacy of patient information. By maintaining confidentiality, the nurse upholds trust and respect in the nurse-family relationship. This principle ensures that sensitive information shared by families is kept secure and not disclosed without permission, thus respecting their autonomy and promoting open communication in healthcare settings.

Correct Answer: D

Rationale: When a client experiences cardiac arrest, their breathing may become insufficient, leading to inadequate elimination of carbon dioxide (CO2) from the body. With reduced CO2 elimination, the level of CO2 in the bloodstream increases, causing respiratory acidosis. This imbalance is characterized by a decrease in blood pH along with an increase in CO2 levels in the blood, resulting in an acidic environment. Respiratory acidosis is the most common imbalance seen in clients who have experienced cardiac arrest, as impaired gas exchange impacts the body's ability to maintain proper acid-base balance.

Correct Answer: B

Rationale: According to the 2017 demography report based on the July 2016 estimate, the Philippine population was approximately 102 million. This data is derived from official census data and estimates made by the Philippine Statistics Authority. As of that time, the country's population had not reached 140 million, 120 million, or 85 million as the other options suggest.

Correct Answer: D

Rationale: When performing an intramuscular (IM) injection, the nurse should insert the needle at a 90-degree angle into the muscle. This angle helps ensure proper and deep penetration into the muscle tissue for effective administration of the medication. It also helps prevent leakage or tissue damage at the injection site. Additionally, inserting the needle at a 90-degree angle facilitates accurate delivery of the medication into the muscle where it can be absorbed properly. Therefore, selecting the correct angle for inserting the needle is critical in ensuring the success and effectiveness of the IM injection.

Correct Answer: B

Rationale: In this scenario, the nurse is asking the patient to elaborate on their feelings and thoughts related to the upcoming surgery. By asking, "What do you fear MOST about your surgery tomorrow?" the nurse is seeking clarification to better understand the patient's concerns and enable effective communication. Seeking clarification involves asking open-ended questions that encourage the patient to express themselves more fully, allowing the healthcare provider to address their specific worries or needs more effectively.

Correct Answer: B

Rationale: The responsibility of obtaining informed consent typically falls on the physician or the healthcare provider who is performing the procedure or treatment. Informed consent is a process where the healthcare provider explains the procedure, its risks, benefits, possible alternatives, and potential outcomes to the patient or their legal representative. The patient must have a comprehensive understanding of these aspects before agreeing to the treatment. While nurses, nurse managers, anesthesiologists, midwives, and other healthcare professionals may assist in the consent process by providing information or clarifications, the ultimate responsibility lies with the physician. This is because the physician is usually the one with the expertise and knowledge about the specific procedure or treatment being performed.