Nokea
A 17-year-old unmarried, pregnant client with drug addiction is a high school dropout, homeless, and has a history of past abuse arrives at the clinic for her first prenatal visit. Which findings should the nurse document as health risk factors for the client? (Select all that apply)
- A. age
- B. school dropout
- C. drug addiction
- D. All of the above
Correct Answer: D
Rationale: All these factors - age, school dropout, drug addiction - are significant health risk factors for the client. Being young, a high school dropout, and struggling with drug addiction can lead to various complications during pregnancy, such as poor prenatal outcomes and social challenges. These factors can impact the client's overall health and well-being, highlighting the importance of addressing them during prenatal care.
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During a prenatal class for expectant mothers, what topic should be included to ensure the health of both the mother and the baby?
- A. importance of taking prenatal vitamins
- B. how to handle common discomforts of pregnancy
- C. preparing for labor and delivery
- D. breastfeeding techniques
Correct Answer: A
Rationale: The correct answer is the importance of taking prenatal vitamins. Prenatal vitamins are crucial for the health of both the mother and the baby as they provide essential nutrients required for fetal development. While handling common discomforts of pregnancy (choice B) is important for maternal well-being, it does not directly impact the health of the baby. Preparing for labor and delivery (choice C) focuses more on the delivery process rather than the overall health of the mother and baby during pregnancy. Breastfeeding techniques (choice D) are relevant postpartum, not during the prenatal period, and do not directly impact the health of the baby during pregnancy.
The healthcare professional is planning a health fair to promote cancer awareness and prevention. Which activity is most likely to increase participation?
- A. offering free cancer screenings
- B. distributing pamphlets on cancer prevention
- C. hosting a guest speaker who is a cancer survivor
- D. providing informational booths on different types of cancer
Correct Answer: A
Rationale: Offering free cancer screenings is the most likely activity to increase participation in the health fair. Providing direct services such as screenings not only attracts participants but also promotes early detection, which is crucial in cancer prevention. Distributing pamphlets, hosting a guest speaker, or providing informational booths are informative but may not have the same impact in driving participation as the opportunity for free screenings.
A client with a history of seizures is admitted with status epilepticus. Which medication should the nurse prepare to administer?
- A. Phenytoin (Dilantin)
- B. Diazepam (Valium)
- C. Lorazepam (Ativan)
- D. Carbamazepine (Tegretol)
Correct Answer: C
Rationale: In the management of status epilepticus, the initial medication of choice is a benzodiazepine to rapidly terminate the seizure activity. Lorazepam (Ativan) is preferred over Diazepam (Valium) due to its longer duration of action and lower risk of respiratory depression. Phenytoin (Dilantin) and Carbamazepine (Tegretol) are not the first-line agents for the acute treatment of status epilepticus, making them incorrect choices in this scenario.
A school nurse is developing a health risk screening protocol for use at an elementary school. What information is most important for the nurse to include in this protocol?
- A. annual flu vaccination status
- B. weight and height measurement
- C. total cholesterol level
- D. long bone deformity testing
Correct Answer: B
Rationale: Weight and height measurements are crucial components of health screenings in children as they help assess growth patterns and identify potential health concerns such as obesity or growth disorders. Monitoring weight and height regularly can aid in early intervention and prevention of health issues. Annual flu vaccination status, total cholesterol level, and long bone deformity testing are not typically primary components of routine health screenings in elementary school children and may not directly contribute to identifying common health risks in this population.
When caring for a client with a tracheostomy, which action should the nurse take first when performing tracheostomy care?
- A. Remove the inner cannula.
- B. Clean the stoma with normal saline.
- C. Change the tracheostomy ties.
- D. Suction the tracheostomy.
Correct Answer: D
Rationale: Suctioning the tracheostomy is the priority action because it ensures a patent airway before proceeding with any other tracheostomy care interventions. This step helps clear secretions and maintain airway patency, which is crucial for the client's respiratory status. Removing the inner cannula, cleaning the stoma, or changing the tracheostomy ties can follow once the airway is clear. Therefore, options A, B, and C are secondary actions compared to suctioning the tracheostomy.