Which of the following is the initial teachinggiven to the patient with ALS having problems in communication?

Correct Answer: C

Rationale: In ALS (Amyotrophic Lateral Sclerosis), communication difficulties may occur as the disease progresses and affects the muscles responsible for speech. It is crucial to initiate early measures to assist the patient in communicating effectively. Using pre-signals before the loss of speech can be helpful in maintaining communication with the patient. These pre-signals can include gestures, writing tools, communication boards, or technology-assisted communication devices. By introducing and practicing these pre-signals early on, the patient can adapt and utilize alternative communication methods before the loss of speech becomes more challenging. This proactive approach can significantly improve the patient's ability to communicate and maintain a sense of connection with others.

Correct Answer: C

Rationale: Nurse Mae should utilize performance evaluations to ensure that the staff adheres to their job responsibilities. Performance evaluations are structured assessments that provide a holistic view of an employee's performance against established standards and job responsibilities. By conducting regular performance evaluations, Nurse Mae can objectively measure staff performance, identify areas of strengths and weaknesses, provide feedback for improvement, and set goals for professional development. This tool is essential for monitoring and managing staff performance effectively in a healthcare setting.

Correct Answer: B

Rationale: In the grading system used for edema, +1 indicates no visible edema in the leg, +2 indicates slight edema with indentations that quickly resolve, +3 indicates moderate edema with deeper indentations that may take longer to resolve, and +4 indicates severe edema with very swollen legs. In this case, since the edema is described as slightly swollen, the appropriate grade to document would be +2.

Correct Answer: A

Rationale: The ultimate purpose of record-keeping is to safeguard information. While history, archiving, and storing information are all important functions of record-keeping, safeguarding information stands out as the primary goal. Keeping accurate and accessible records ensures that essential information is secured, protected from unauthorized access, loss, and damage. Safeguarding information also promotes transparency, accountability, and compliance with legal and ethical standards. In the case of Nurse Mely's consideration of teamwork and collaboration in community health nursing, safeguarding the relevant information through precise and organized record-keeping is crucial for effective communication, continuity of care, and successful health outcomes.

Correct Answer: A

Rationale: The purpose of asking Nurse Rosie to submit an Incident Report (IR) is most likely to note patterns of incidences in the same unit. Incident reports are essential tools in healthcare settings to track and analyze unexpected events, errors, or situations that may impact patient care and safety. By collecting and reviewing incident reports, the head nurse can identify trends, patterns, or commonalities in the occurrences within the unit. This information allows for targeted interventions, improvements in practices, and enhanced patient safety. Therefore, asking Nurse Rosie to submit an IR would serve the purpose of noting patterns of incidences in the same unit for proactive and quality care delivery.

Correct Answer: C

Rationale: Opioid analgesics are known to suppress the respiratory centers in the brain, leading to respiratory depression as a side effect. This adverse effect is particularly dangerous and potentially life-threatening, especially in patients who are opioid-naive or when high doses are administered. Therefore, it is crucial for the nurse to closely monitor the patient's respiratory rate, depth, and effort while on opioid analgesic therapy to detect early signs of respiratory depression and intervene promptly to prevent complications. Hypertension, hypoglycemia, and hyperkalemia are not commonly associated with opioid analgesics.

Correct Answer: D

Rationale: The best time for an incontinent patient to take diuretics is at bedtime. This timing allows for increased urine production during the night, consequently reducing the need for frequent toileting during the day. By taking the diuretic at bedtime, the patient can manage their incontinence more effectively and have better rest without disruptions from frequent urination during the day.

Correct Answer: A

Rationale: The clinical presentation of a patient with progressive dyspnea, non-productive cough, fine inspiratory crackles, and HRCT findings of diffuse reticular opacities and traction bronchiectasis is highly suggestive of idiopathic pulmonary fibrosis (IPF). IPF is a specific subtype of ILD characterized by progressive scarring of the lung tissue, leading to the symptoms mentioned above. The presence of reticular opacities and traction bronchiectasis on HRCT is a typical finding in IPF.

Correct Answer: C

Rationale: When controlling severe external bleeding from an extremity, the recommended action is to apply direct pressure with a sterile dressing. Direct pressure helps to stop the bleeding by promoting clot formation and reducing blood flow from the wound. This method is effective in most cases and should be the first response to control bleeding. Elevating the extremity above the level of the heart can be helpful in some cases, but direct pressure is the initial recommended action. Applying a tourniquet proximal to the injury site should only be done as a last resort when other methods are not successful, as it can lead to complications such as tissue damage. Removing any impaled objects can actually worsen the bleeding and should be avoided unless necessary for immediate life-saving measures.