Nurse Maris is correct in identifying whinch of the following is a health resource problem?

Correct Answer: C

Rationale: The correct answer, C, reflects a health resource problem. The absence of a midwife in the community means that there is a lack of a critical health resource necessary for providing essential health services, especially for pregnant women and infants. This directly impacts the access to healthcare services and can contribute to negative health outcomes, such as high maternal mortality rates. The other options do not directly address a health resource problem but rather focus on specific issues or conflicts within the community.

Correct Answer: A

Rationale: The patient presents with gradual, painless visual field loss in both eyes, particularly in the peripheral vision, which is characteristic of glaucoma. The elevated intraocular pressure (IOP) on tonometry further supports a diagnosis of glaucoma. Open-angle glaucoma is the most common type of glaucoma and typically presents insidiously with a slow progression of vision loss. In open-angle glaucoma, the drainage angle of the eye remains open but becomes less efficient over time, leading to increased intraocular pressure and optic nerve damage. This results in peripheral visual field loss. Closed-angle glaucoma, on the other hand, presents more acutely with sudden eye pain, redness, and blurred vision due to a sudden increase in intraocular pressure from a blocked drainage angle. Age-related macular degeneration and diabetic retinopathy typically do not present with elevated IOP or peripheral visual field loss.

Correct Answer: C

Rationale: In Participative Action Research (PAR), the core idea is to empower the community by involving them in the research process. By actively engaging community members in all stages of the research, they gain a sense of ownership and are empowered to take action based on the research findings. This approach ensures that the solutions generated are relevant, sustainable, and community-driven. Therefore, participation and engagement of the community is the step that will empower the community in PAR, unlike the other options where the focus is on external individuals or entities.

Correct Answer: B

Rationale: Spondylosis is a condition characterized by degenerative changes in the intervertebral discs, leading to narrowing of the disc space and the formation of osteophytes (bone spurs). This degenerative process commonly occurs with aging and can cause symptoms such as neck or back pain, stiffness, and reduced range of motion. Spondylosis is a common finding on imaging studies like X-rays and MRI scans in individuals over the age of 50 and is a natural part of the aging process of the spine.

Correct Answer: B

Rationale: Baby Sharon's APGAR score can be determined by assessing five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each criteria is given a score of 0, 1, or 2 points, with 2 being the highest score.

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: Deep vein thrombosis (DVT) is a serious condition that requires prompt medical intervention. The presence of calf pain, swelling, and warmth in a postpartum client are concerning signs of a potential DVT. By notifying the healthcare provider immediately, appropriate diagnostic tests, such as ultrasound imaging, can be ordered to confirm the diagnosis. Timely treatment with anticoagulant medication can then be initiated to prevent complications such as pulmonary embolism. Applying warm compresses or encouraging ambulation may exacerbate the condition by promoting clot dislodgement, making immediate notification of the healthcare provider the most appropriate nursing action in this situation.

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: The patient's presentation with renal failure, confusion, seizures, asterixis, and a sweet odor to the breath, along with laboratory findings of severe metabolic acidosis, hyperkalemia, and elevated BUN and creatinine levels, is consistent with uremic encephalopathy. Uremic encephalopathy is a neurological complication of acute or chronic renal failure resulting from the buildup of uremic toxins in the blood, leading to various neurological symptoms such as confusion and seizures. The sweet odor to the breath can be attributed to the presence of urea, a waste product that accumulates in renal failure. Other metabolic abnormalities like hyperkalemia and severe metabolic acidosis are also common in renal failure. It is crucial to promptly recognize and manage uremic encephalopathy to prevent further neurological complications.