One of the post-caesarian patients has a private duty nurse and is responsible for providing holistic care to her patient during the shift. What modality of nursing care is implemented?

Correct Answer: B

Rationale: Total care nursing is a nursing care delivery model where one nurse is assigned to provide comprehensive care to a patient for an entire shift. In this case, the private duty nurse is providing holistic care to the post-caesarian patient during the shift, which aligns with the principles of total care nursing. This approach allows the nurse to focus on the individual needs of the patient and provide all aspects of care, promoting continuity and personalized attention. Total care nursing ensures that the patient receives consistent and dedicated care from the same nurse, enhancing the patient's overall experience and outcomes.

Correct Answer: A

Rationale: Breastfeeding is actually a protective factor against acute otitis media (AOM) in children due to the antibodies and nutrients present in breast milk that help strengthen the immune system and the Eustachian tube function. Swimming, exposure to cigarette smoke, and poor hygiene are all risk factors for AOM. Swimming can introduce water into the ears, which can lead to infections. Exposure to cigarette smoke can irritate the mucous membranes in the respiratory tract and increase the risk of infections. Poor hygiene can lead to the spread of bacteria that can cause AOM.

Correct Answer: B

Rationale: It is important for the nurse to have a direct and easily accessible means of communication with the patient who is expected to be in and out of the hospital due to their chronic illness like leukemia. By asking for the patient's phone number, the nurse can quickly reach out to them for updates, clarification, or any urgent matters that may arise. This direct communication line helps in ensuring continuity of care and addressing the patient's needs promptly. This approach is more practical and efficient compared to options such as asking the patient to call the hospital number listed in the yellow pages or relying on chart information which may not always be up to date. Writing down the number and giving it to the ward clerk may cause unnecessary delays in communication.

Correct Answer: B

Rationale: In the situation of an obstetric emergency requiring immediate delivery, the priority nursing action is to prepare the delivery room for the birth. This involves ensuring that all necessary supplies and equipment are readily available, the bed is adjusted to the appropriate position, and the healthcare team is prepared to assist with the birth. By expeditiously preparing the delivery room, the healthcare team can facilitate a safe and timely delivery for both the mother and the baby. Notifications to the healthcare provider, administering intravenous fluids, and continuous fetal monitoring can be done simultaneously but preparing the delivery room takes precedence to ensure a prompt response to the emergent situation.

Correct Answer: C

Rationale: Mastitis is an infection of the breast tissue that may occur in postpartum clients. When a postpartum client exhibits signs of mastitis, including breast tenderness, erythema, and warmth, it is crucial to notify the healthcare provider immediately. Prompt medical evaluation is necessary to determine the appropriate treatment plan, which may include antibiotics. Delay in treatment can lead to complications, such as abscess formation. Encouraging the client to continue breastfeeding and applying warm compresses may provide some relief but do not address the underlying infection. Administering oral antibiotics would require a prescription from the healthcare provider, hence notifying the provider is the most appropriate initial nursing action in this situation.

Correct Answer: B

Rationale: The most appropriate nursing diagnosis for the individual described is "Ineffective individual coping." This is because the individual has been facing challenges in both academic (failing math class) and personal (substance dependence) aspects of his life. The repeated failures in his math class and the substance dependence for three years indicate that he might be struggling to cope with stressors and challenges in his life effectively. By identifying this nursing diagnosis, the nurse can focus on helping the individual develop effective coping strategies to manage and overcome these difficulties.

Correct Answer: D

Rationale: It is important for the nurse to acknowledge the patient's preference and respect their choice. By responding with "So then you would prefer to speak with your doctor?" the nurse is showing understanding and willingness to accommodate the patient's request. This response helps to maintain a positive and respectful interaction with the patient.

Correct Answer: D

Rationale: Calcium channel blockers are often prescribed for the management of hypertension because they can help relax blood vessels and slow the heart rate, thus reducing blood pressure. One of the major adverse effects associated with calcium channel blockers is bradycardia (slow heart rate) or even more rarely, tachycardia (fast heart rate). Therefore, in a patient prescribed a calcium channel blocker for hypertension, the nurse should closely monitor for any signs and symptoms of tachycardia as it can be a serious adverse effect that needs prompt evaluation and intervention to prevent complications.

Correct Answer: A

Rationale: Reporting observed signs of child abuse to the Department of Social Welfare Development (DSWD) is the best nursing action in cases of suspected child abuse. DSWD is the government agency tasked with protecting the welfare of children and families. They have the necessary authority and resources to investigate and intervene in cases of child abuse. Reporting to DSWD ensures that professional social workers and experts will step in to assess the situation, provide necessary interventions, and ensure the safety of the child. It is important to involve the appropriate authorities who are trained to handle cases of child abuse effectively. Reporting to the DSWD helps in safeguarding the well-being of the child and taking the necessary steps to address the situation appropriately.