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Tuberculosis from Mycobacterium bovis in Binational Communities, United States

Volume 14, Number 6–June 2008

Timothy C. Rodwell,* Marisa Moore,†‡ Kathleen S. Moser,† Stephanie K. Brodine,§ and Steffanie A. Strathdee*

*University of California San Diego School of Medicine, La Jolla, California, USA; †County of San Diego Health and Human Services, San Diego, California, USA; ‡Centers for Disease Control and Prevention, San Diego; and §San Diego State University, San Diego

Suggested citation for this article

Abstract
The epidemiology of tuberculosis (TB) in the United States is changing as the incidence of disease becomes more concentrated in foreign-born persons. Mycobacterium bovis appears to be contributing substantially to the TB incidence in some binational communities with ties to Mexico. We conducted a retrospective analysis of TB case surveillance data from the San Diego, California, region from 1994 through 2005 to estimate incidence trends, identify correlates of M. bovis disease, and evaluate risk factors for deaths during treatment. M. bovis accounted for 45% (62/138) of all culture-positive TB cases in children (<15>M. bovis incidence increased significantly (p = 0.002) while M. tuberculosis incidence declined (p<0.001).>M. bovis cases from 2001 through 2005 were in persons of Hispanic ethnicity. Persons with M. bovis were 2.55× (p = 0.01) as likely to die during treatment than those with M. tuberculosis.

The pattern of tuberculosis (TB) in the United States is changing as the incidence of TB disease becomes more concentrated in foreign-born persons. Of the annual total US TB cases, >54% are now concentrated in persons born outside of the United States (1); in communities with high immigration, the proportion can exceed 70% (2). TB prevention and treatment strategies, particularly those in communities on the border with Mexico, will need to be adapted to accommodate the changing epidemiology of TB (3).

San Diego, California, together with its sister city Tijuana-Tecate, Mexico, is the largest binational metropolitan region in the United States, accounting for 34% of the southern border population (4). In San Diego County, the Hispanic population has grown from 20% to 29% in the past 15 years (5). Of the total annual TB cases in San Diego, >70% occurred among foreign-born persons, of whom nearly half originated from Mexico (2). A review of culture-positive TB cases in San Diego County in the late 1990s indicated that 6.6% of all adult TB cases and 39% of all pediatric (<15>Mycobacterium tuberculosis, the most common TB pathogen in the United States, but were instead caused by M. bovis, a pathogen more often associated with TB in cattle (6). This finding represented the highest reported proportional incidence of TB from M. bovis among industrialized countries (7).

M. bovis is a pathogen in the complex of bacteria that includes M. tuberculosis, which causes TB in humans and animals. TB from M. bovis has been generally considered rare in the United States after its successful eradication from cattle in the mid-1900s (8), but wider use of laboratory tools for species-level diagnosis of TB pathogens has started to shed light on an unexpected regional presence of M. bovis in communities with large Hispanic populations. While M. bovis TB has been most often documented in Hispanic communities with close proximity to Mexico (6,9), a recent review of M. bovis cases in New York City indicates that the problem is not limited to US regions that border Mexico (10).

The clinical and pathologic characteristics of M. bovis TB is indistinguishable from M. tuberculosis TB in most cases, but there are relevant considerations for prevention and treatment strategies in communities where M. bovis contributes to TB incidence. First, M. bovis is thought to be spread to humans primarily through consumption of raw dairy products and inhalation of infectious droplets from cattle (11,12), with only minimal human-to-human transmission (13). Second, M. bovis is almost universally resistant to the key antituberculous drug pyrazinamide (PZA), which necessitates a 9-month treatment duration instead of the standard 6-month, short-course therapy, which is possible with PZA in the treatment regime. Third, higher mortality rates during treatment may be associated with M. bovis (14).

Multidrug-resistant (MDR) strains of M. bovis (15–17), the high proportional incidence of M. bovis (9,18) in pediatric TB cases, and frequent HIV co-infection (19) are important additional considerations in developing effective treatment and prevention strategies for M. bovis. To document the trends and the effect of M. bovis on TB epidemiology, we examined TB case surveillance data from 1994 through 2005 in San Diego County and identified risk factors related to M. bovis disease and deaths during treatment in the last 5 years.

Analysis

Trends

Trends in TB incidence were evaluated by using Poisson regression with time in years as the predictor variable, case number as the dependent variable, and population size as an additional exposure variable. Trend lines for M. bovis and M. tuberculosis were based on incidence predicted by Poisson regression fitted to the data. Trends in proportional incidence of M. bovis cases (relative to all TB cases) were assessed with a χ² test for trend.

Correlates of M. bovis Disease

Demographic and clinical variables shown previously to be associated with TB diagnoses (6) were compared between M. bovis and M. tuberculosis. Variables significant at the 5% level by χ² test in univariate analyses were entered into a multiple logistic regression model. The final model was derived by using the likelihood ratio method (22).

Analysis of Mortality Rates during Treatment

All deaths that occurred from the time that a TB case was reported until treatment was completed were documented with death certificates and recorded in TB case files. For the purposes of this study, causes of death in M. bovis and M. tuberculosis case files were transcribed from death certificates or California state death records and collated into 7 major causes of death based on the most common causes.

We investigated the apparently higher mortality rates during treatment among M. bovis cases relative to M. tuberculosis cases (14) by using a multiple logistic regression analysis with M. bovis as the exposure variable; death before treatment was completed as the outcome variable; and demographic and clinical variables as potential covariates. Univariate differences between causes of death in M. bovis and M. tuberculosis cases were analyzed with the Fisher exact test.

Results

Trends

Analysis of TB trends from 1994 through 2005 included 3,291 culture-positive cases of TB and excluded 806 cases (20%) that were based only on national and local clinical case definitions. Among all culture-positive cases, M. bovis was isolated in 8% (265/3,291) and M. tuberculosis in 92% (3,026/3,291). M. bovis accounted for 45% (62/138) of all culture-positive TB cases in children <15>>15 years of age). No cases of M. bovis occurred in children <12>

Correlates of M. bovis Disease

Of the 1,324 culture-positive TB cases reported from 2001 through 2005, M. bovis accounted for 10% (132/1,324), comprising 54% (29/54) of cases among children <15>>15 years of age). Of the M. bovis TB cases, >96% were found in persons of Hispanic ethnicity, and 60% were among those of known Mexican origin. Univariate analysis indicated that sex, previous TB episode, and sputum AFB smear results were not significantly different between M. bovis and M. tuberculosis case-patients (Table 2). No MDR TB cases were identified among the M. bovis cases, whereas 1.5% of the M. tuberculosis cases had initial isolates that were MDR (defined as resistant to at least both isoniazid and rifampin). All of the M. bovis isolates were resistant to PZA, whereas 0.8% of the M. tuberculosis cases were PZA resistant. Of the 1,316 TB cases included in the multiple logistic regression model, factors associated with M. bovis disease included Hispanic ethnicity, multisite disease, being 5–14 years of age, and having extrapulmonary disease with a normal chest radiograph. HIV co-infection was not significantly more associated with M. bovis disease compared with M. tuberculosis (p = 0.08; Table 3).

Analysis of Mortality Rates during Treatment

Of 1,324 culture-positive TB case-patients, 1,119 were evaluated in the analysis of mortality rates during treatment. Fifteen percent (205/1,324) were excluded because of missing data on case survival, including patients who were lost to follow-up or moved during treatment. Of the 1,119 cases, 110 (19 M. bovis and 91 M. tuberculosis) patients died during TB treatment (n = 81) or before treatment was begun (n = 29). M. bovis patients who died during treatment were treated for a similar duration (mean 61 days, standard deviation [SD] 93.9) as M. tuberculosis patients (mean 60 days, SD 101.3).

No deaths during treatment were recorded in the pediatric M. bovis TB case-patients; 1 pediatric death was recorded among the M. tuberculosis TB treatment cases. In a multivariate analysis (n = 1,119), M. bovis patients were 2.55× (p = 0.01) as likely to die before treatment completion than M. tuberculosis patients, after differences in age, race and ethnicity, country of birth, chest radiograph abnormalities, multisite disease, and HIV status were accounted for (Table 4). Univariate analyses of the causes of death in M. bovis and M. tuberculosis cases showed no significant differences (p>0.05) except for the category of "other noninfectious disease,"which was overrepresented in the M. tuberculosis group (Table 5).

Discussion

From 1994 through 2005, incidence of M. bovis TB cases in San Diego County increased in absolute number, as a proportion of total TB cases, and relative to the population. In contrast, TB incidence caused by M. tuberculosis declined during the same period. M. bovis cases were concentrated in persons of Hispanic descent, especially those of Mexican origin, and among those <15>M. bovis accounted for 45% of the culture-positive cases. Deaths during treatment were largely confined to adults and were twice as high in M. bovis TB case-patients when compared with M. tuberculosis patients.

Our findings indicate that the incidence of TB caused by M. bovis in southern California is substantially higher than the national rate of 1.5% estimated from TB surveillance data (23) but is similar to the proportional incidence (13%) among Mexican-born case-patients in New York, New York. It was previously hypothesized that TB attributed to M. bovis in San Diego is most likely being driven by recent infections in children and largely reactivated latent infections in adults, secondary to HIV co-infection (6). Our findings confirm the continued high incidence of M. bovis in children >12 months of age, but the role of HIV co-infection in M. bovis case-patients relative to M. tuberculosis cases is less clear.

Almost half of the culture-positive pediatric TB cases in this binational region of >3 million persons were caused by M. bovis, which has clinical implications. Since M. bovis is intrinsically resistant to PZA, a critical component of the standard 6-month, short-course treatment for M. tuberculosis, M. bovis treatment is usually extended to 9 months of isoniazid and rifampin (14). In southern California, and perhaps other Hispanic communities with close ties to Mexico, empiric extended TB treatment for children without culture-positive disease, particularly those with a history of consuming unpasteurized dairy products, should be considered.

Although one quarter of the M. bovis TB case-patients were co-infected with HIV, HIV was not significantly more associated with M. bovis TB compared with M. tuberculosis in our study or in the previous M. bovis study in this community (6). Confidence in this finding is somewhat limited because 40% of the TB case-patients did not have their HIV status reported. However, because most of the case-patients with an unknown HIV status were <15>55 years of age, the age groups at lowest risk for HIV, these missing data likely did not mask an association if one exists.

HIV co-infection plays a role in the epidemiology of adult M. bovis TB, but likely the growing Hispanic population with close ties to Mexico, and not HIV, is the major driving force behind the increasing number of M. bovis cases we observed. Given the long latency of this disease, the unclear role of airborne transmission in M. bovis TB (13), and the fluid population dynamics of the San Diego region, however, the true population at risk and what might be behind the trends observed are difficult to describe. The relative contributions of reactivated latent M. bovis infection compared with recent infection could not be discerned in our study, but prudent prevention strategies would include a focus on eliminating consumption of unpasteurized dairy products in both adults and children in the United States and Mexico.

Our study confirms earlier preliminary findings (14) that M. bovis case-patients appear to be more than twice as likely to die before TB treatment completion compared with M. tuberculosis patients, despite being treated for the same mean number of days. The association of higher mortality rates during M. bovis treatment persisted after HIV, multisite disease, age, and ethnicity were accounted for. Causes of death related to noninfectious disease, such as malignancy and noninfectious gastrointestinal pathologies, were underrepresented in the M. bovis cases (0 vs. 25%), but, overall, the M. bovis and M. tuberculosis cases were not significantly different with regard to all causes of death.

In mouse models, evidence indicates that certain strains of M. bovis are more virulent than M. tuberculosis strains (24), but those findings are not generally supported in the literature on human M. bovis TB (7). Although our mortality analysis partially controlled for extent of disease, it did not include information on coexisting conditions, stage of HIV disease, diagnostic delays, and prior access to medical care. Therefore, M. bovis deaths might be accounted for by other factors, such as health disparities or treatment differences, which warrant further investigation.

Public health measures to control TB are currently focused on interrupting person-to-person transmission by promptly identifying and treating infectious patients and ensuring that they do not expose new contacts until treatment has rendered them noninfectious. Based on our data, these strategies, which have proven to be effective at reducing M. tuberculosis cases in San Diego and most regions of the United States, appear to be less effective in controlling M. bovis, suggesting that human-to-human transmission of M. bovis is less likely an important mode of transmission in this community. The consumption of contaminated dairy products has been proposed to be the primary source of human TB from M. bovis (25). This hypothese is supported by the findings of an investigation of M. bovis cases in New York that indicated the likely source of infection was unpasteurized cheese from Mexico (10). Additionally, San Diego pediatric M. bovis cases occur only after the age of, when children are typically first exposed to dairy products (6), and M. bovis was also recently cultured from unpasteurized cheese seized at the San Diego–Mexico border (26,27).

Because of the widespread adoption of pasteurization of all commercially available dairy products in the United States, as well as the aggressive US state agricultural health programs designed to keep dairy cattle free from M. bovis disease, the threat of M. bovis in US dairy products was largely eliminated in the mid-20th century (8). The San Diego–Tijuana binational region, however, shares one of the busiest border crossings in the United States with Baja, Mexico (28), where M. bovis is prevalent in cattle and consumption of unpasteurized dairy products is a common cultural practice (29–32). Mexican dairy products, including the popular queso fresco (soft, unpasteurized cheese), may be brought into the United States for personal use and are sometimes distributed illegally (27). Given our finding that >90% of M. bovis cases in San Diego occurred in Hispanics, most of whom were born in Mexico, consumption of unpasteurized dairy products from Mexico is likely a major risk factor for M. bovis TB in San Diego. Collaboration with Mexico on prevention strategies, from education to regulation of the production of unpasteurized dairy products, and elimination of M. bovis from dairy cattle will be required in the long term to ensure that this mode of transmission is eliminated.

Limitations

A growing awareness of M. bovis as a cause of TB in San Diego since 1980 could have introduced a sampling bias into our trend estimates, but this possible bias is unlikely to have had a considerable effect in the years 1994 through 2005 as reported here. All suspected TB cases in San Diego County are reportable to the health department, and the county laboratory has consistently conducted testing to distinguish all M. tuberculosis complex isolates as either M. bovis or M. tuberculosis since 1994. The proportion of TB cases based only on clinical diagnosis and not species level culture has remained relatively level, at ≈20% of all reported TB cases. Increased efforts to obtain specimens for culture in pediatric TB cases in the years under study did not appear to change the proportion of culture-positive cases during the study period.

The cohort of TB case-patients who were not culture-positive and thus excluded from this analysis was significantly different from the study group. The <15-year>M. bovis TB, the total incidence of M. bovis, particularly in children, may be underestimated in our study.

Conclusions

San Diego, California, while unique in many respects because of its close proximity to Mexico, is possibly representative of other communities in the United States with large and growing Hispanic populations with ties to Mexico. The considerable and growing incidence of TB from M. bovis, especially in children, and the observed number of deaths during treatment in these cases is of serious concern. It raises the question of the importance of incorporating routine species-level identification into US TB surveillance as the national TB incidence shifts to persons born outside the United States. This surveillance will be greatly facilitated by the national genotyping project implemented by the US Centers for Disease Control and Prevention in 2004 (33), and its use will be particularly important for communities with strong ties to Mexico.

Acknowledgments

The authors thank Benjamin Sanchez for his assistance with dataset preparation and Richard Shaffer and Bohan Kolody for comments on early drafts of the manuscript.

Dr Rodwell received financial support from National Institutes of Health: HRSA and T32 #DA023356 as well as fellowship no. CF07-SD-302 from the California HIV/AIDS Research Program at the University of California and internal funds from the endowment of the Harold Simon Chair, Division of International Health and Cross-Cultural Medicine, University of California, San Diego.

See the entire journal:
http://www.cdc.gov/eid/content/14/6/909.htm

High blood pressure patients advised to use home monitors

DALLAS, May 22 — People with hypertension should routinely monitor their blood pressure at home to help manage the disease, according to a new joint scientific statement from the American Heart Association, American Society of Hypertension and the Preventive Cardiovascular Nurses’ Association.

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The statement is published online in Hypertension: Journal of the American Heart Association, the Journal of the American Society of Hypertension and the Journal of Clinical Hypertension and printed in the June issue of Journal of Cardiovascular Nursing.

“High blood pressure is notoriously difficult to treat to goal – many patients fail to reach target levels despite treatment, and studies show home monitoring can help,” said Thomas G. Pickering, M.D., D.Phil., chair of the statement writing group. “Blood pressure measurement and tracking could be improved with home monitoring by the patients themselves, in much the way people with diabetes monitor their blood sugar levels with home glucose monitors.”

He said there is strong evidence that the traditional way of measuring blood pressure in adults can be misleading. Studies indicate that between 10 percent and 20 percent of people diagnosed with high blood pressure in the doctor’s office actually have the ‘white coat effect,’ meaning that their pressures are normal under other conditions, but rise in the medical setting.

“It is also believed that some people with normal blood pressures in their doctors’ offices have pressures that spike to potentially dangerous levels in other situations,” said Pickering, director of the Center for Behavioral Cardiovascular Health at Columbia Presbyterian Medical Center in New York, N.Y.

According to the statement, home monitoring is particularly useful in the elderly, in whom both blood pressure variability and the white coat effect are increased, as well as in patients with diabetes, patients with kidney disease and in pregnant women.

Pickering noted that because everyone’s blood pressure is highly variable during the day, taking one reading at a doctor’s office every few months doesn’t give a complete picture of a person’s condition. Home monitors can take multiple measurements during each session, and can be used at different times of day. Many monitors also store and average blood pressure readings over time, providing crucial data for patients to take to their physicians so they can work as a team to diagnose and treat the condition. Many types of home monitors are relatively inexpensive at less than $100.

“Home blood pressure monitoring also gives patients the physiologic feedback they need to see regarding blood pressure,” says Nancy Houston Miller, R.N., co-author and former president of the Preventive Cardiovascular Nurses Association. “Rather than three to four office blood pressure checks per year, if they measure blood pressure at home in addition to following up with their healthcare provider, patients are likely to achieve goals more quickly and be confident that medicines are working for them.” She also states that nurses and nurse practitioners have a significant role to play in interpreting data from blood pressure devices and educating patients about needed lifestyle interventions and medications.

“We’re encouraged by this joint statement on the value of home blood pressure monitoring and confident it will be helpful in reducing the incidence of heart attack, stroke and kidney disease,” said Suzanne Oparil, M.D., president of the American Society of Hypertension.

Hypertension increases the risk of heart attack and stroke and controlling it is essential to reducing that risk. The statement writing group said home blood pressure monitoring is evidence-based healthcare that can improve the quality and lower the cost of caring for the 73 million people with hypertension.

Although earlier American Heart Association guidelines have included home monitors, this is the first statement to have detailed recommendations on their use.

• Patients should purchase oscillometric monitors with cuffs that fit on the upper arm. They should use a proper fitting cuff, and ask a healthcare provider the proper way to use the monitors.

• Wrist monitors are NOT recommended.

• Patients should take two or three readings at a time, one minute apart, while resting in a seated position. The arm should be supported, with the upper arm at heart level, and feet on the floor (back supported, legs uncrossed). It’s important to take the readings at the same time each day, such as morning and evening, or as a healthcare professional recommends.

• Use of a home monitor can confirm suspected or newly diagnosed hypertension and rule out diagnosis for patients whose readings at the doctor’s office don’t reflect their actual pressures over time.

• Home monitoring can be used to evaluate the response to any type of antihypertensive treatment, and to motivate patients to take their medications regularly.

• The target goal for treatment with a home monitor is less than 135/85 millimeters of mercury (mmHg), or less than 130/80 in high-risk patients.

“I hope this leads to a new era in patient-doctor partnerships,” Pickering said. “I think this is a very healthy trend and with a condition like high blood pressure, it really does depend on the patients remembering to change their lifestyles or remembering to take their pills.”

Only a few of the home blood pressure devices on the market have been subjected to proper validation tests such as the Association for the Advancement of Medical Instrumentation (AAMI) and British Hypertension Society (BHS) protocols. Several devices have failed the tests. An up-to-date list of validated monitors is available on the BHS Web site, http://www.bhsoc.org/default.stm.

Co-authors include Gbenga Ogedegbe, M.D., M.P.H.; Lawrence R. Krakoff, M.D.; Nancy T. Artinian, Ph.D., R.N.; and David Goff, M.D., Ph.D.

The American Heart Association/American Stroke Association receives funding primarily from individuals. In addition, foundations and corporations – including pharmaceutical, device manufacturers and other companies – make donations and fund specific American Heart Association/American Stroke Association programs and events. Revenues from pharmaceutical and device corporations are disclosed at www.americanheart.org.

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Editor’s note:
The American Heart Association’s online Blood Pressure Management center features Microsoft’s HealthVault tool, which allows patients to track their blood pressure readings, weight and physical activity. Patients can record data as often as they like, view it online in a chart or table, and easily print it to share with their doctor. The high blood pressure Web site also contains educational information and resources that patients can use to help achieve their blood pressure goal. For information about high blood pressure and access to the Blood Pressure Management Center, visit www.americanheart.org/bptools.

NR08-1063 (HYP/Pickering)

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On the web:
http://americanheart.mediaroom.com/index.php?s=43&item=425

Dietary Intake of Dairy Products, Calcium, and Vitamin D and the Risk of Hypertension in Middle-Aged and Older Women

Date: Published online February 7, 2008

Summary: Eating low-fat foods and dairy products high in calcium and vitamin D decreased the risk of developing high blood pressure and heart disease in a large group of middle-aged and older women. However, taking calcium and vitamin D supplements did not affect the risk of high blood pressure or heart disease.

Why it’s important: Only limited information exists on the association between dairy products, calcium and vitamin D and high blood pressure and very few of these studies have been prospective in nature ie a study in which the subjects are identified and then followed over a period of time. This prospective study involving nearly 30,000 women over age 45 provides definitive information on the effects of dairy products, and the calcium and vitamin D they contain, on blood pressure. It also evaluates the effects of calcium and vitamin D supplements. The effects of diet on blood pressure could have major public health implications. Blood pressure remains a major public health problem in the United States. Even lowering it a little for individuals could have a major effect on the health of the U.S. population.

What’s already known: Previous studies have suggested that the more dairy products people eat, the lower their risk for developing metabolic syndrome (a group of metabolic risk factors in one person), type 2 diabetes and heart disease. The effect is thought to result from calcium and other nutrients found in dairy products. Scientists believe that high intake of calcium reduces the levels of specific hormones and antioxidants. That may reduce the amount of calcium that goes into cells. When that happens, more fat is metabolized in the cell and less fat is generated by cells. Vitamin D is critical for the absorption of calcium and the metabolism of the two are interrelated. Studies of high blood pressure and dairy products in children, young adults and adults in Mediterranean countries indicate that higher amounts of dairy products and lower blood pressure are related. The federally funded Dietary Approach to Stop Hypertension (DASH) study showed that diets rich in fruits, vegetables and low-fat dairy products with low total and saturated (animal product) fats reduced blood pressure in people who had and who did not have high blood pressure compared to a diet that was rich in fruit and vegetables alone.

How this study was done: This study used data collected from the Women’s Health Study, which was designed to find out whether taking low-dose aspirin and vitamin E could lower the risk of developing heart disease and cancer. As part of the study, the women aged 45 and above filled out a 131-item questionnaire about the food they ate. The researchers included women in the study who answered the questions completely and had no sign of high blood pressure or heart disease. They analyzed information from 28,886 women and calculated how much of each food item the women ate daily, including dairy products. They also found out which women took supplements or pills containing calcium and vitamin D. During the 10 years of the study, the researchers identified women who developed high blood pressure. They then ranked the women by the amount of dairy products they reported eating.

What was found: Over 10 years, 8,710 women developed high blood pressure. The more dairy products and food containing vitamin D the women ate, the lower their risk of developing high blood pressure. The researchers found that women who drank two or more servings of fat-free milk or low-fat dairy products daily reduced their high blood pressure risk by 10 percent compared to women who consumed the low-fat dairy products less than once a month. However, the study showed no benefit from taking supplements containing calcium or vitamin D. Higher-fat dairy products did not protect the women from high blood pressure, but they did not increase their risk either.

The researchers, led by Lu Wang, M.D., Ph.D., of the division of preventive medicine at Brigham and Women’s Hospital in Boston, wrote: “Because dairy products account for nearly 80 percent of total calcium intake in the American diet, our findings on total dietary calcium suggested a major role of this nutrient in mediating the beneficial effects of dairy products in the prevention of hypertension. Milk fortified with vitamin D is the main source of vitamin D intake in the American diet.” However, they also wrote: “It remains unclear why benefits are observed for low-fat dairy products but not for high-fat dairy products.” They think that the saturated fats found in these products weigh against the beneficiary factors that reduce blood pressure.

The study is limited. The eating habits of the women were measured only once – at the start of the study. Also, the researchers only found out if women developed high blood pressure during the study period if the women reported it. Although the researchers do not think that the women’s lower blood pressure risk was associated with an overall better eating pattern, they couldn’t rule it out. The women in the study were mostly white and professionals, which could affect the findings.

The bottom line: Drinking a glass of fat-free milk or eating other low-fat dairy products could lower your blood pressure somewhat. Taking supplements containing calcium and vitamin D probably will not.

Journal: Hypertension

Journal citation: Hypertension. 2008;51:1-7



This content is reviewed regularly. Last updated 03/28/08.

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On the web:

http://www.americanheart.org/presenter.jhtml?identifier=3055292

American Heart Association Survey Reveals Americans Lack Confidence in Lifesaving Skills for Common Cardiac Emergency

DALLAS, May 28 — Most Americans don’t believe they could perform cardiopulmonary resuscitation (CPR) and use an automated external defibrillator (AED) to help save a life in a cardiac emergency, according to a recent American Heart Association survey.

In an online survey of more than 1,100 adults, 89 percent said they were willing and able to do something to help if they witnessed a medical emergency. Yet only 21 percent were confident they could perform CPR, and only 15 percent believed they could use an AED in an emergency. More than half of those surveyed didn’t recognize an AED in a typical setting. Survey respondents reported lack of confidence, concern about legal consequences and fear of hurting a victim as reasons they would not take action in a cardiac emergency.

The American Heart Association released the survey results as part of the inaugural National CPR/AED Awareness Week, June 1-7. The intent of the week is to encourage the public to get CPR training and learn how to use an AED to reduce death and disability from sudden cardiac arrest (SCA).

Unfortunately, only about six percent of out-of-hospital SCA victims survive. Without immediate, effective CPR, the chance of surviving out-of-hospital SCA decreases seven to 10 percent per minute. Even if CPR is performed, defibrillation with an AED is required to stop the abnormal rhythm and restore a normal heart rhythm.

“We think it’s critical for people to get CPR training and learn how to use an AED,” said Lance Becker, M.D., professor of emergency medicine at the University of Pennsylvania in Philadelphia and spokesperson for the American Heart Association. “CPR and AED use are inextricably linked in the SCA survival chain, and it’s crucial that bystanders take rapid action. If more people are trained and respond, we can save thousands more lives.”

The American Heart Association provides classroom CPR and AED instruction, as well as a self-paced CPR Anytime Kit that includes an inflatable manikin and instructional DVD. The association’s adult Hands-OnlyTM CPR educates untrained people to call 9-1-1 and push hard and fast on the center of an adult SCA victim’s chest until help arrives.

Designed to be simple and intuitive, AEDs are available in many public places such as schools, airports and workplaces and will guide the user through the process with clear, calm voice cues. The devices are strategically deployed and maintained to ensure that they are ready in a medical emergency, and will not deliver a shock unless a shockable rhythm is detected.

“There’s no reason for people to be afraid to act,” Becker said. “We want people to feel confident that whatever action they choose — whether using an AED or performing conventional CPR or adult Hands-Only CPR — they are doing something to help, which could be a lifesaving decision.”

SCA survivor Jenifer Fergusson knows first hand about the importance of people taking action. The New York native suffered an SCA at work when two coworkers immediately came to her aid. Due to their quick actions, Jenifer survived her cardiac event.

“My coworkers are true heroes,” she said. “I’m so grateful they had the skills and courage to perform CPR and use a defibrillator when I went into cardiac arrest. Thankfully, my company had an AED onsite. If my colleagues hadn’t acted or the AED was not available, I might not be here today.”

Other results from the survey include:
• Sixty-five percent said they had received CPR training, but only 18 percent reported having received AED training.
• Two-thirds of those trained in using CPR and AEDs were required to for their jobs, school or the military.
• Respondents’ reasons for not getting trained included not thinking about it or not being required.
• Most respondents (89 percent) believe that providers of adult day care should be trained in using CPR and AEDs. Most (86 percent) also want training for child care workers.
• The majority (88 percent) of people surveyed support requiring schools to have emergency plans, and 65 percent want public places to have AEDs on site.

Philips Healthcare sponsored the survey to raise awareness of CPR and AEDs.
For more information about the survey results and National CPR/AED Awareness Week, visit americanheart.org/CPR&AEDweek or call 1-877-AHA-4CPR.

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Editor’s Note: For full survey results, go to americanheart.org/CPR&AEDweek

About the American Heart Association
Founded in 1924, the American Heart Association today is the nation’s oldest and largest voluntary health organization dedicated to building healthier lives, free of heart disease and stroke. These diseases, America’s No. 1 and No. 3 killers, and all other cardiovascular diseases claim nearly 870,000 lives a year. In fiscal year 2006-07 the association invested more than $554 million in research, professional and public education, advocacy and community service programs to help all Americans live longer, healthier lives. To learn more, call 1-800-AHA-USA1 or visit americanheart.org.

About Royal Philips Electronics
Royal Philips Electronics of the Netherlands (NYSE: PHG, AEX: PHI) is a global leader in healthcare, lighting and consumer lifestyle, delivering people-centric, innovative products, services and solutions through the brand promise of “sense and simplicity”. Headquartered in the Netherlands, Philips employs approximately 134,200 employees in more than 60 countries worldwide. With sales of USD 42.5 billion (EUR 27 billion) in 2007, the company is a market leader in medical diagnostic imaging and patient monitoring systems, energy efficient lighting solutions, as well as lifestyle solutions for personal wellbeing. News from Philips is located at www.philips.com/newscenter.

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How to Improve Sudden Cardiac Arrest Survival Addendum to Media Release
National CPR/AED Awareness Week

People who could benefit from CPR training and/or how to use an AED:
-- Parents
-- Pool owners
-- People with family members who have a history of heart-related medical
problems
-- People who live in high density areas (traffic and other factors could
impede emergency responders' timely arrival on the scene)
-- People who live in rural areas (emergency responders may have to
travel a long distance to reach the scene)
-- Anyone who is a potential bystander

Things a caregiver could do to prepare for an emergency cardiac situation:
-- Get CPR training
-- Learn how to use an AED
-- Ask if places where you and your family spend time, like the gym,
daycare and the workplace train their employees in CPR and have an AED
onsite.
-- Make sure you know where the AED is at those locations, so you are
prepared for an emergency
-- Update your training so you get skills practice

Things a company could do to be prepared for an emergency cardiac situation:

• Have an emergency action plan in place
• Practice your emergency action plan
• Train employees in CPR
• Have an AED onsite
• Train employees to use an AED

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On the web: http://americanheart.mediaroom.com/index.php?s=43&item=429

Gut superbug causing more illnesses, deaths

ATLANTA - The number of people hospitalized with a dangerous intestinal superbug has been growing by more than 10,000 cases a year, according to a new study.

The germ, resistant to some antibiotics, has become a regular menace in hospitals and nursing homes. The study found it played a role in nearly 300,000 hospitalizations in 2005, more than double the number in 2000.

The infection, Clostridium difficile, is found in the colon and can cause diarrhea and a more serious intestinal condition known as colitis. It is spread by spores in feces. But the spores are difficult to kill with most conventional household cleaners or antibacterial soap.

C-diff, as it's known, has grown resistant to certain antibiotics that work against other colon bacteria. The result: When patients take those antibiotics, competing bacteria die off and C-diff explodes.

This virulent strain of C-diff was rarely seen before 2000.

"The nature of this infection is changing. It's more severe," said Dr. L. Clifford McDonald, a Centers for Disease Control and Prevention expert who was not part of the study.

There are other factors that play into the rise of C-diff cases as well, including a larger of number of patients who are older and sicker. "And there may be some overuse and inappropriate use of antibiotics," said Dr. Marya Zilberberg, a University of Massachusetts researcher and lead author of the study.

The Zilberberg study was based on a sample of more than 36 million annual discharges from non-governmental U.S. hospitals. That data was used to generate the study's national estimates.

The research is being published in the June issue of Emerging Infectious Diseases, a CDC publication.

Using other scientists' estimates, the study concluded that 2.3 percent of the cases in 2004 were fatal — about 5,500 deaths. That was nearly double the percentage of C-diff-related cases that ended in death in 2000.

Many of the people who died had other health problems. The study did not try to determine if Clostridium difficile was the main cause of death in each case, Zilberberg said.

But earlier research concluded the infection is the underlying cause of thousands of deaths annually, and the problem is getting worse.

C-diff has become an acute health concern in Canada, where it was blamed for 260 deaths at seven Ontario hospitals recently, and 2,000 deaths in Quebec since 2002.

The Association for Professionals in Infection Control and Epidemiology is currently working with U.S. hospitals to study prevalence of the infection and what infection control measures seem to work best.

"This is not a time for alarm, but more a time for educating health professionals to understand this particular pathogen," said Kathy Warye, chief executive of the Washington, D.C.-based association.

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On the Net:

Yahoo! Health: http://health.yahoo.com/news/ap/deadly_bacteria.html

The CDC publication: http://www.cdc.gov/ncidod/EID/index.htm

December 2006 Sample Practice Test 2

TO BE EDITED: No Answers Yet...

Instructions: Get you pen/pencil and a piece of paper for your answers. Answers are located at the bottom of this post.

COMMUNITY HEALTH NURSING AND CARE OF MOTHER AND CHILD

1. A child who is 13 months has fast breathing if he has:

A. 30 breaths per minute or more
B. 60 breaths per minute
C. 40 breaths per minute or more
D. 50 breaths per minute

2. Which of the following is true about discharge planning?

A. basic discharge plans involve referral to community resources
B. discharge plans involve referral to community resources
C. simple referral involves use of a discharge planner
D. complex referral includes interdisciplinary collaboration

3. A nurse may keep opened vials of OPV for use in the next session if:

A. you have taken out the vaccine at the health center for some other reasons
B. the expiry date has not passed
C. the vaccines have been stored at a temperature between 0 deg C and 8 deg C
D. the vaccines have change its color

4. The primary preventive measures against HIV-AIDS is:

A. withdrawal
B. virus killing drugs
C. foams and gels use
D. condom use

5. Ms. Amodia, RN works for a home health agency and cares for an older adult mental patient. On reporting to work, she observes numerous bruise and red marks on her patients face. Her patient seems upset. Ms. Amodia suspects that either abuse has occurred. Ms. Amodia should:

A. contact the mobile police to investigate the abuse
B. make an appointment with an elder adult counselor
C. wake her son and ask him who would hurt his mother
D. call her supervisor right away to report the findings

6. If there develops severe pre-eclampsia, what would be the drug you would anticipate to be prescribed and that you would have to administer?

A. a loop diuretic
B. magnesium sulfate
C. ranitidine (zantac)
D. a non-steroidal inflammatory agent

7. As a community health nurse you always bear in mind that the purpose of empowering victims of violence is to:

A. tell them how to solve their problems
B. convince victims to leave their abusers
C. help clients become aware that they have control over their lives
D. develop safety escape plans for them

8. Maria is developing constipation from being on bed rest. What measure would you suggest she take to help prevent this?

A. drink 8 full glasses of fluid such as water daily
B. drink more milk, increased calcium intake prevents constipation
C. eat more frequent small meals instead of three large ones daily
D. walk for at least half an hour daily to stimulate peristalsis

9. A bilateral amputee is assisted by his wife and children to the commode for bowel evacuation. This example best demonstrates the family’s assistance to meet which need?

A. Elimination
B. activity
C. nutrition and metabolism
D. health perception and health maintenance

10. Which of the following is the most important reason for doing a literature review for constructing a research study?

A. helpful information on demographic instrument development could be uncovered
B. existing knowledge about the identified problem can be found
C. a determination of the study’s feasibility could be extrapolated
D. the research design can be copied from another study

11. Martina develops endometritis. What would be the best activity for her?

A. lying in bed with a cold cloth on her forehead
B. reading while resting in a trendelenburg position
C. sitting with her feet elevated while playing cards
D. walking around her room listening to music

12. Grace sustained a laceration on her leg from automobile accident. Why are lacerations of lower extremities potentially more serious among pregnant women than other?

A. lacerations can provoke allergic responses due to gonadotropic hormone release
B. a woman is less able to keep the laceration clean because of her fatigue
C. healing is limited during pregnancy so these will not heal until after birth
D. increased bleeding can occur from uterine pressure on leg veins

13. Fely has diarrhea for 2 days. She has sunken eyes, skin pinch goes back very slowly, and she is drinking poorly and irritable. She is not able to drink and there is no blood in the stool. How will you classify Fely’s illness?

A. persistent diarrhea
B. some dehydration
C. severe dehydration
D. no dehydration

14. The infectious agent that causes pulmonary tuberculosis is:

A. mycobacterium tubercle
B. Hansen’s bacillus
C. Wuchereria bancrofti
D. mycobacterium diphtheria

15. Your client, who happens to be female resident of the barangay you are covering, is an adult survivor who states: “Why couldn’t I make him stop the abuse? If I were stronger person, I would have been able to make him stop. Maybe it was my fault to be abused”. Based on this, which would be your most appropriate nursing diagnosis?

A. social isolation
B. anxiety
C. chronic low self-esteem
D. ineffective family coping

16. Maybelle is also scheduled to have an amniocentesis to test for fetal maturity. What instructions would you give her before this procedure?

A. void immediately before the procedure to reduce your bladder size
B. no more amniotic fluid forms afterward, that is why only a small amount is removed
C. the intravenous fluid infused to dilate your uterus does not hurt the fetus
D. the x-ray used to reveal your fetus position has no long-term effects

17. When planning teaching strategy for a pregnant woman, the nurse should do which of the following?

A. give information about how the woman can manage the specific problems she identifies as relevant in her life
B. omit information related to minor pains of pregnancy to prevent the woman from developing hypochondria
C. provide all information to the woman in a group session with other pregnant women so she can have someone to discuss it with
D. during the first prenatal visit, teach a woman the care measures necessary for health promotion throughout the pregnancy

18. Which of the following symptoms is LESS commonly noted in EARLY pregnancy?

A. frequency of urination
B. chills and fever
C. varicosities
D. Braxton Hicks’ Contractions

19. Bonnie, 3 months pregnant, has reported for her first prenatal visit. The nurse should instruct her to do which of the following?

A. eat more dairy products and green leafy vegetables to provide an additional 300 calories each day
B. increase her intake of carbohydrates-breads and sweets to prevent protein metabolism
C. eat whenever she feels hungry because her body will let her know when she needs nutrients and extra calories
D. limit intake of amino acids to prevent development of diabetic ketoacidosis

20. The nurse is assisting Mr. and Mrs. Cruz to prepare for childbirth in the home setting. Which of the following supplies should be readily available for the infant immediately after birth?

A. vitamin K to avoid bleeding
B. mild soap without perfume so as not to irritate the skin
C. bulb syringe to suction fluid and mucous from the mouth
D. heating lamp to avoid chilling from water evaporation

21. Which of the following could be included in the outcome criteria for a patient with a nursing diagnosis, “Knowledge deficit related to potential for altered tissue perfusion in fetus or mother related to maternal cardiovascular disease”?

A. bedrest is maintained at home after the 36th week of gestation
B. fetal heart rate will remain between 120 and 160 beats a minute
C. jugular vein distention is evident when lying at 45 degrees
D. maternal blood pressure maintained above 150 systolic

22. Pregnant women should be taught to be careful to avoid accidental injury. They are prone to falls for which of the following reasons?

A. additional weight from pregnancy may disturb balance when walking
B. fetal activity stimulates the nerves of the legs and causes weakness
C. high levels of hormones often impair judgment resulting in reckless behavior
D. increased adrenalin released during pregnancy causes women to move faster than usual

23. When a nurse uses the IMCI model, the IMCI chart uses illness classification, e.g. the pink row needs:

A. no specific treatments such as antibiotics
B. urgent referral
C. appropriate antibiotics
D. no urgent measures

24. Which of the four signs of good attachment is true in this statement?

A. the chin should touch the breast while the mouth is wide open and while the lower lip is turned inward more areola is visible above than below
B. the chin should touch the breast, the mouth is wide open while the lower lip turned outward and more areola visible above than below
C. the chin should touch the breast while the mouth is wide open while the lower lip turned outward and more areola visible below than above
D. the chin should touch the breast while the mouth is wide open and the lower lip turned inward, more areola is visible above than below

25. Which type of research inquiry investigates the issues of human complexity ( e. g. understanding the human expertise?)

A. positivism
B. quantitative research
C. logical position
D. natural inquiry

26. Carol is 15 months old and weighs 5.5 kgs and it is her initial visit. Her mother says that Carol is not eating well and unable to breastfeed, he has no vomiting, has no convulsion and not abnormally sleepy or difficult to awaken. Her temperature is 38.9 deg C. Using the integrated management of childhood illness or IMCI strategy, if you were the nurse in charge of Carol, how will you classify her illness?

A. a child at a general danger sign
B. very severe febrile disease
C. severe pneumonia
D. severe malnutrition

27. Why are small for gestational age newborns at risk for difficulty maintaining body temperature?

A. their skin is more susceptible to conduction of cold
B. they are preterm so are born relatively small in size
C. they do not have as many fat stored as other infants
D. they are more active than usual so they throw off comes

28. Oxytocin is administered to Rita to augment labor. What are the first symptoms of water intoxication to observe for during this procedure?

A. headache and vomiting
B. a swollen tender tongue
C. a high choking voice
D. abdominal bleeding and pain

29. Which of the following treatment should NOT be considered if the child has severe dengue hemorrhagic fever?

A. use plan C if there is bleeding from the nose or gums
B. give ORS if there is skin Petechiae, persistent vomiting, and positive tourniquet test
C. give aspirin
D. prevent low blood sugar

30. In assessing the patient’s condition using the Integrated Management of Childhood Illness approach strategy, the first thing that a nurse should do is to:

A. ask what are the child’s problem
B. check the patient’s level of consciousness
C. check for the four main symptoms
D. check for the general danger signs

31. A child with diarrhea is observed for the following EXCEPT:

A. how long the child has diarrhea
B. skin Petechiae
C. presence of blood in the stool
D. signs of dehydration

32. The child with no dehydration needs home treatment. Which of the following is NOT included in the care for home management at this case?

A. give drugs every 4 hours
B. continue feeding the child
C. give the child more fluids
D. inform when to return to the health center

33. Ms. Jordan, RN, believes that a patient should be treated as individual. This ethical principle that the patient referred to:

A. beneficence
B. nonmaleficence
C. respect for person
D. autonomy

34. When patients cannot make decisions for themselves, the nurse advocate relies on the ethical principle of:

A. justice and beneficence
B. fidelity and nonmaleficence
C. beneficence and nonmaleficence
D. fidelity and justice

35. Being a community health nurse, you have the responsibility of participating in protecting the health of people. Consider this situation: Vendors selling bread with their bare hands. They receive money with these hands. You do not see them washing their hands. What should you say/do?

A. “Miss, may I get the bread myself because you have not washed your hands”
B. All of these
C. “Miss, it is better to use a pick up forceps/ bread tong”
D. “Miss, your hands are dirty. Wash your hands first before getting the bread”

36. If a child with diarrhea has 2 or more signs in the IMCI pink row chart, the classification will be:

A. moderate dehydration
B. some dehydration
C. no dehydration
D. severe dehydration

37. If the capillary refill takes more than 3 seconds it may mean:

A. the child is in shock
B. the child is dehydrated
C. circulatory failure
D. the child is alright

38. Leprosy is a chronic disease of the skin and peripheral nerves. Which of the following signs are present in the early stage?

A. loss of eyebrows
B. clawing of fingers
C. contractures
D. thickening or painful nerves

39. In asking the mother about her child’s problem the following communication skills should be used EXCEPT:

A. use words that the mother understand
B. give time for the mother to answer the question
C. listen attentively
D. ask checking questions

40. Patients eligible under the short term chemotherapy (STC) are the following EXCEPT:

A. all newly discovered and reconfirmed sputum positive cases
B. those with cavitary lung findings after two successive negative sputum examination
C. patients without having been given consent for anti-TB treatment
D. patients willing to undergo treatment

41.When planning comfort measures to help the woman in active labor to tolerate her pain, the nurse must consider which of the following?

A. early labor contractions are usually regular, coordinated, and very painful
B. if women are properly prepared, they will require no pain medication to manage their pain
C. pain medication given during the latent phase of labor is not likely to impair contractions
D. the acceleration phase of labor can be a time of true discomfort and high anxiety

42. Francis is admitted in active labor. The nurse locates fetal heart sounds in the upper left quadrant of the mother’s abdomen. The nurse would recognize which of the following?

A. Francis will probably deliver very quickly and without problems
B. This indicates Francis will probably have a breech delivery
C. The fetus is in the most common anterior fetal positions
D. this position is referred to as being left anteriopelvic

43. While interviewing a woman in labor, the nurse would address which of the following?

A. whether the pregnancy was planned
B. the use of medications during pregnancy
C. maternal concerns regarding fetal health
D. all of the above

44. If a woman will be placing her baby for adoption, which of the following nursing measures should be implemented during the labor stages?

A. avoid discussing the baby during the historical assessment to minimize the woman’s anxiety
B. support the woman as needed by accepting the decisions she makes regarding holding the baby
C. protect the woman from visitors and family members who might try to change her mind
D. take the baby away as soon as possible after birth to prevent bonding from occurring

45. During the third stage of labor, the nurse may have which of the following responsibilities?

A. administration of intramuscular Oxytocin to facilitate uterine contractility
B. monitoring for blood loss greater than 100 cc, which would indicate gross hemorrhage
C. noting if the placenta makes a Schultz presentation, which is a sign of gross complication
D. pushing down on the relaxed uterus to aid in the removal of the placenta

46. Immediately following episiotomy repair, the nurse would do which of the following?

A. cleanse the woman’s anal area, then perineum and vulva, to remove any fecal incontinence or vaginal secretions
B. monitor the woman for shaking and complaints of chill sensations, which may indicate an adverse reaction to medications
C. palpate the uterus fundus for size, consistency and position and take vital signs to obtain baseline data
D. remove all coverings except a clean, light hospital gown to prevent the development of postpartal fever

47. Mr. Tony has been hospitalized for months following special spinal cord surgery. The boys club in his hometown was renamed the Tony boys club, and a parade is planned to honor Mr. Tony. Such community action should positively influence Mr. Tony’s:

A. self-perception and self concept
B. cognition and perception
C. health perception and health maintenance
D. coping and stress tolerance

48. Which of the following conditions is not true about contraindication to immunization?

A. do not give BCG if the child has known hepatitis
B. do not give BCG if the child has known AIDS
C. do not give DPT to a child who has recurrent convulsion or active neurologic disease
D. do not give DPT2 or DPT3 to a child who has had convulsions within 3 days of DPT1

49. Which of the following might prevent the conduct of a research study?

A. in order to gather data for the research, excessive risk to subject is required
B. costs for conducting the study are low compared to the potential benefits from the researcher
C. the identified problem is covered in the literature
D. the research problem is based on untested nursing theories

50. Marsha is concerned she may loose an excessive amount of blood with cesarean surgery. What is the usual amount of blood loss with cesarean birth?

A. 250 – 350 ml
B. 500 – 1000 ml
C. 100 – 220 ml
D. 300 – 500 ml

51. If the child is 4 months, which of the following questions SHOULD NOT be included in checking the general danger signs?

A. ask if the child is eating well during illness B. ask if the child is able to breastfeed
C. ask if the child has had no convulsion
D. ask if the child vomits everything

52. Arnie, like all newborns, can loose body heat by conduction. Under which conditions is this most apt to occur?

A. if the nursery is cooled by air conditioning
B. if the infant is wet from amniotic fluid
C. if Arnie is placed in a cold bassinet
D. if there is a breeze from an open window

53. You have just entered Mr. Tiangco’s room and observed him lying on the floor next to the bed. The side rails on the bed are down. When you asked Mr. Tiangco what happened, he replies. “I was asleep and the next thing I knew I was on the floor”. Which of the following examples of documentation is MOST APPROPRIATE for this situation?

A. Lying on floor next to bed. No complaints verbalized. Side rails down. Appears to have fallen out of bed while asleep.
B. Mr. Tiangco was found lying on the floor next to his bed. When asked what happened, he stated “ I was asleep and the next thing I knew I was on the floor”.
C. Lying on the floor, side rails down. Rolled out of bed while asleep.
D. Mr. Tiangco fell out of bed while asleep; both side rails were left down.

54. The application of public health, medical and engineering practices to health services and effectiveness of workers may be termed as:

A. community health
B. occupational health
C. school health
D. mental health

55. A literature review should be:

A. brief and limited
B. broad and theoretical
C. systematic and exhaustive
D. general and context

56. The Santiago Family lives in a makeshift house in Julugan, Tanza, Cavite. Composed of 8 members, the eldest son Rhio is 7 years old. Rhean is 6, Queenie and Quency are twins 5, Peter is 4 and the youngest is 6 months old named Oscar. Aling Rosa works in a laundry earning Php 1,500.00 a month and husband Mang Sony works as fish vendor earning Php 150.00 per day. Peter and the twins are enrolled in the day care. Rhio and Rhean stopped studying to help their parents for their younger brothers and sisters. With the current condition besetting the Santiago family, which of the following interventions can lend assistance to them?

A. refer the children to a hospice care facility
B. assist Aling Rosa to be referred to the DSWD for livelihood assistance
C. give Aling Rosa’s family a Php 2,000.00 worth of capital for them to put a fishball stand
D. advise Aling Rosa to use contraceptive pills

57. Every year we discover new methods or gadgets to improve man’s life. The research typed used of this nature is:

A. applied
B. developmental
C. experimental
D. quantitative

58. When should the mother give complementary foods to a 5 months old infant?

A. if the child gives adequate weight for his age
B. if the child shows interest in semi solid foods
C. supplementary foods should be given before breastfeeding
D. if the child is breastfed less than 8 times in 24 hours

59. Hepatitis A is differentiated from hepatitis B by their mode of transmission. Hepatitis B is transmitted through:

A. insect bites
B. urine
C. transfusion and injection
D. fecal waste

60. The nurse wants to immunize a 1 year old child for measles. The child has been classified as having pneumonia and no anemia and not very low weight. The child’s mother does not want her child to be immunized and instead they will just return as soon as the child is better. How will the nurse explain the importance of immunizing the child with measles now?

A. the child’s condition is not a hindrance to immunization according to W.H.O.
B. the child has lower resistance and more prone to disease
C. the child will recover faster if the child will be immunized
D. it is the child’s schedule to have the immunization

61. To implement the case finding aspect of TB control, sputum examination should be done to the following groups:

A. children 0-9 years old with cough for 2 weeks or more
B. all persons of all ages above 1 year with symptoms indicative of tuberculosis
C. children below 10 years old with fever for 3-5 days
D. all persons ages 10 years and over with progressive loss of weight

62. Mr. Barmonte was brought home with an advance directive, but the nurse is not sure that she can follow his wishes. The nurse should:

A. follow the directive even though the nurse is uncomfortable with the directives
B. call Mr. Barmonte’s lawyer
C. discuss with the interdisciplinary team in charge of Mr. Barmonte and the organization’s ethics committee
D. ignore the advance directive

63. A term concerning body resistance which refers to protein present in the serum of the blood:

A. antibodies
B. antitoxin
C. antigen
D. allergen

64. A health care service in which risk factors are identified, occupational safety measures reduce, and a public education program begun is:

A. health promotion
B. illness prevention
C. treatment facility
D. rehabilitation

65. A community health nurse (CHN) visits the Gomez family weekly. Although family income seems adequate, Mrs. Gomez is unable to budget it over a 4-week period. The nurse asks what may be done to help Mrs. Gomez shrugs her shoulders and says, “Tomorrow may never come.” Mrs. Gomez’s reaction is described as:

A. reflecting her culture, values, and time orientation
B. one of not caring about her family’s needs
C. her belief that income may not be adequate as perceived by the CHN
D. indicating that her budget needs is a private matter

66. A positive or negative feeling toward a person, object, or idea is known as a/an:

A. merit
B. value
C. moral
D. attitude

67. When the nurse assists the clients in understanding personal values, this is an example of value:

A. validation
B. discovery
C. clarification
D. choice

68. While doing a nutritional assessment of a low-income family, the community health nurse determines the family’s diet is inadequate in protein content. The nurse could suggest which of the following foods to increase protein content with little increase in food expenditure?

A. oranges and potatoes
B. potatoes and rice
C. rice and macaroni
D. peas and beans

69. A new mother who is breast-feeding her baby asks the nurse when she should start her feeding baby vegetables. The nurse would suggest the MOST APPROPRIATE age to begin vegetables is:

A. 3 to 4 months
B. 4 to 5 months
C. 6 to 8 months
D. 9 to 12 months

70. Assessment areas for the nurse is working with the family on health promotion strategies would include:

A. the television shows that they watch
B. the family and all the relative’s statuses
C. the perceived health status and illness patterns of the family
D. the mental status of family and friends

71. The nurse manager wishes to implement a new way of determining the vacation schedule for the staff. The senior staff opposes the change while the newer staff seems more accepting of the change. An effective strategy for resolving this difference in acceptance would be to:

A. explain that the change will occur as designed, regardless of the staff’s preference
B. tell the staff that if they really do not want the change, it will not be implemented
C. provide extensive and detailed rationale for the proposed change
D. encourage each side to share their views with each other

72. The following are the duties of the Public Health Nurse EXCEPT:

A. leave to the BHW the responsibilities of educating the community
B. provision of nursing care to the sick and well individuals
C. provision of technical and administrative support to rural health midwives
D. conduct of pre and post consultation conference for clinic patients

73. An 8 month old has fast breathing if he has:

A. 40 breaths per minute
B. 55 breaths per minute
C. 38 breaths per minute
D. 45 breaths per minute

74. The following are the concerns of the Public Health Nurse on the third trimester of pregnancy EXCEPT:

A. advice for the mother to take oral contraceptive
B. where to give birth
C. proper timing in the separation of mother to other siblings
D. type of feeding

75. When a child with persistent diarrhea returns for follow-up visit after 5 days, the nurse should ask the mother if the diarrhea has stopped when:

A. the child has less than 3 loose bowels per day
B. the child has 4 semi formed stool
C. the child has 5 formed stools
D. the child has 3 loose stools/day

76. In barangay Y, one of the identified problems is unavailability of toilet facility for the residents. The appropriate intervention is:

A. secure donations in the form of toilet bowls
B. ask help from local government
C. none of the above
D. conduct a community assembly and discuss the consequences of this problems

77. A home visit is a professional interaction between the community health nurse and his patient or the family. Where could the nurse get available information about the patient or the family to be visited?

A. document file
B. records and reports
C. doctor’s office
D. family health record

78. In planning a home visit, the nurse considers the individual needs. Which of the following is a priority?

A. needs of all family members
B. needs recognized by the family
C. follow-up of medication and treatment
D. clinic schedules after home visit

79. Which of the following is the FIRST action of the nurse during a home visit?

A. greet the client or the household members
B. state the purpose or objective of the visit
C. give necessary health teaching
D. inquire about welfare and health condition of the client

80. Which factor must be considered by the nurse as vital to determine frequency of the home visit?

A. available resources
B. policy of the agency
C. acceptance of the family
D. past nursing services

81. Eating habits of the family has changed due to the existing fast food establishment in the area. What health risk should you warn the family?

A. food-borne infection
B. indigestion
C. increase weight
D. hand washing

82. To show a mother how to help her to have good attachment of the infant during breast feeding. Which of the following statement SHOULD NOT be included?

A. place the infant in your most convenient position
B. touch the infant’s lips with her nipples
C. wait until the infant’s mouth is widely open
D. move the infant quickly onto her breast, aiming the infant’s lips well below the nipple

83. When members of the community identify needs, work on its solutions with confidence in the spirit of cooperation. The process is:

A. nurse’s professional effort
B. government assistance
C. community organizing
D. leadership through traditional leaders

84. In assessing the level of family cohesion, you have determined that the family is very close and has very high loyalty, and members are highly dependent on one another. You would document this as which level of cohesion:

A. separated
B. enmeshed
C. connected
D. disengaged

85. Mrs. Ayuyao, 77 year old, has been admitted with pneumonia. Her husband asks the nurse about the living will. As a license nurse, you remember that living wills:

A. are legally binding in all states
B. allow the court to decide when the care can be given
C. allow the individual to express his or her wishes regarding care
D. allow health workers to withhold fluids and medications

86. Maybelle is scheduled to have an ultrasound examination. What instructions would you give her before her examination?

A. The intravenous fluid infused to dilate your uterus does not hurt the fetus
B. you will need to drink at least 3 glasses of fluid before the procedure
C. void immediately before the procedure to reduce your bladder size
D. you can have medicine for pain for any contractions cause by the test

87. What is the most common type of health problem seen in the health care system?

A. poor prenatal care
B. lack of information available to patients
C. immobility
D. increased rate of chronic disease

88. Which of the following is the best type of disease prevention?

A. immunization
B. yearly physical exam
C. community social events
D. behavior that promotes health

89. Nurses who deliver community-based care must have which of the following qualities?

A. adaptability
B. tolerance of various lifestyle
C. ability to be self-directed
D. all of the above

90. A nurse has scheduled a hypertension clinic. This service would be an example of which of the following types of health care?

A. tertiary prevention
B. secondary prevention
C. primary prevention
D. protection

91. When providing care in a home, how might the nurse best implement infection control?

A. cleanse the hands before and after giving direct patient care
B. remove the patient’s wound dressings from the home
C. dispose off patient’s syringes in the patient’s garbage
D. disinfect all work areas in the patient’s home

92. Which of the following is a leading health problem of school-age children?

A. earaches
B. attention disorders
C. obesity
D. malnutrition

93. If the child does not have ear problem, what should the nurse do?

A. check for tender swelling behind the ear
B. check for ear pain
C. check for ear drainage
D. got to diet question, check for malnutrition

94. Nona had her pelvic measurement taken. What size should the ischial tuberosity diameter be, to be considered adequate?

A. have the width of the symphysis pubis
B. 8 cm
C. 11 cm
D. twice the width of the conjugate diameter

95. In classifying the child’s illness using the IMCI color-coded triage, each illness is classified according to whether it requires the following EXCEPT:

A. urgent pre-referral treatment and referral
B. simple advice on home management
C. immunization
D. specific medical treatment

96. Which of the following is an example of hostile environment in terms of sexual harassment?

A. the boss assures you of a big promotion if you go out on a couple of dates with him
B. your supervisor makes masturbatory gestures every time you walk pass him
C. the personnel manager hints that the job will be yours if you cooperate sexually with him
D. your boss suggests that your “raise” is dependent upon having sex with him

97. Which among these activities is the concern of the Primary Level?

A. administration of BCG vaccine for a 10 days old baby
B. insertion of a nasogastric tubes to patients
C. administer diuretics such as furosemide per doctors order
D. regulate intravenous fluid drop rates

98. Which of the following vaccine in the Expanded Program of Immunization have a 4 weeks interval?

A. OPV
B. AMV
C. BCG
D. Tetanus Toxoid

99. The nurse who is planning a health promotion program with clients in the community will have the LEAST focus on:

A. assisting the clients to make informed decisions
B. organizing methods to achieve optimal mental health
C. reducing genetic risk factors for illness
D. providing information and skills to maintain lifestyle changes

100. A holistic belief system by the nurse would be most evident if the nurse:

A. incorporates client perceptions of health when planning care
B. encourages behavior modification program
C. supports goal-directed learning to improve health
D. accepts death as an outcome of life