Upon further assessment, you notices that she had any scratches on her right ankle, a resulting infection, and cellulitis. When you asked her about the scratches, the patient states, "Oh, my cat might have been using my leg as a scratiching post again and I did not even feel it." Which diabetic complicatons suspect the patient to have?

Correct Answer: A

Rationale: The patient's lack of sensation in her right leg, allowing her cat to scratch her without her noticing, is indicative of neuropathy. Neuropathy is a common diabetic complication characterized by nerve damage that can result in loss of sensation or altered sensation in different parts of the body, including the extremities. In this case, neuropathy has likely affected the patient's right lower extremity, leading to her inability to feel the cat scratching her leg and resulting in the unnoticed scratches, infection, and subsequent cellulitis.

Correct Answer: C

Rationale: In this situation, the most appropriate response for the palliative nurse is to validate the patient's feelings of guilt and offer support to address their concerns. It is important to acknowledge the patient's emotions and help them navigate through their guilt in a compassionate and understanding manner. By validating their feelings, the nurse can create a safe space for the patient to express their concerns and work towards finding solutions to alleviate their guilt. This approach fosters trust and a therapeutic relationship between the patient and the nurse, ultimately promoting emotional well-being and facilitating open communication.

Correct Answer: B

Rationale: The statement "Multigravida patient has shorter labor" is the best response to Patient Josephine's question about her shorter labor compared to previous deliveries. In obstetrics, it is commonly observed that labor tends to be shorter in patients who have had previous pregnancies (multigravida patients) due to factors such as prior cervical changes and previous stretching of the birth canal. This phenomenon is known as "multigravida cervical efficiency," and it can lead to faster and more efficient labors in subsequent pregnancies for women who have had previous deliveries.

Correct Answer: C

Rationale: Republic Act 9173, also known as the Philippine Nursing Act of 2002, mandates the compulsory immunization of children below 8 years. This law ensures that young children receive necessary vaccines to protect them from preventable diseases and promote public health. RA 9173 is a significant legislation that highlights the importance of immunization in safeguarding the well-being of children in the Philippines.

Correct Answer: D

Rationale: The desired nursing action to help the pregnant patient make a decision on breastfeeding is to assist in identifying a breastfeeding goal and plan. When patients are indecisive about breastfeeding, it is essential for the nurse to support them in setting specific goals and creating a plan that aligns with their values and circumstances. This approach can help the patient feel empowered and confident in their decision-making process. Providing pamphlets and books (choice A) may be helpful, but personalized assistance in identifying a breastfeeding goal and plan is more likely to address the patient's individual needs and concerns. Providing ample time for the patient to decide (choice B) is important, but guidance and support in setting a clear goal can facilitate the decision-making process. Referring the patient to a nutritionist (choice C) may be beneficial for dietary concerns but may not directly address the decision-making process regarding breastfeeding.

Correct Answer: A

Rationale: In a patient with acute gastrointestinal bleeding requiring urgent intervention, the healthcare team should prioritize performing endoscopic hemostasis with mechanical or thermal techniques. Endoscopy allows for direct visualization of the source of bleeding in the gastrointestinal tract, enabling targeted interventions such as clipping, cauterization, or injection of epinephrine to achieve hemostasis. This approach is effective in managing acute bleeds and can help stop the bleeding quickly, reducing the need for more invasive procedures or surgeries. Administering proton pump inhibitors (PPIs) may be considered for acid-related bleeding, but it is not the primary intervention for acute bleeding requiring urgent management. Strict bed rest may not be necessary and can increase the risk of complications such as deep vein thrombosis. Transfusion of fresh frozen plasma may be indicated if there is evidence of coagulopathy, but addressing the bleeding source should be the initial priority to

Correct Answer: B

Rationale: Phenomenology is a qualitative research design that focuses on exploring and understanding the lived experiences of individuals within their "life-worlds." It seeks to uncover the essence of a phenomenon as it is experienced subjectively by individuals, aiming to understand the underlying meanings and perspectives through in-depth interviews, observations, and reflections. In phenomenology, researchers aim to set aside their own biases and preconceptions to capture the essence of the participants' experiences as they see them. This approach allows researchers to gain insight into how individuals make sense of and interpret their world, providing rich and detailed accounts of unique human experiences.

Correct Answer: B

Rationale: Uterine hyperstimulation, also known as tachysystole, is a condition where the uterus contracts too frequently and/or too forcefully, leading to a decreased uterine blood flow. This can result in maternal fatigue and decreased oxygenation to the fetus, as mentioned in the scenario. Uterine hyperstimulation can be caused by several factors, including the excessive use of uterotonic medications, such as oxytocin, or the presence of uterine abnormalities.

Correct Answer: A

Rationale: Tricyclic antidepressants (TCAs) are known to have anticholinergic effects, which can lead to various cardiovascular side effects, including orthostatic hypotension, tachycardia, and potential hypertension. While hypotension is a possible adverse effect, hypertension is more commonly associated with TCAs. Therefore, it is essential for the nurse to monitor the patient for signs of hypertension, such as elevated blood pressure readings, to prevent any adverse outcomes and ensure the patient's safety while on this medication.