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A client with a history of heart failure is admitted with pulmonary edema. Which finding requires immediate intervention?
- A. Peripheral edema.
- B. Oxygen saturation of 88%.
- C. Jugular vein distention.
- D. Productive cough with pink, frothy sputum.
Correct Answer: D
Rationale: A productive cough with pink, frothy sputum is a classic sign of pulmonary edema, indicating fluid in the lungs. This finding requires immediate intervention to prevent respiratory compromise and worsening of the condition. Peripheral edema (Choice A) is a manifestation of heart failure but is not as urgent as addressing pulmonary edema. Oxygen saturation of 88% (Choice B) is low and requires attention, but the pink, frothy sputum signifies acute respiratory distress. Jugular vein distention (Choice C) can be seen in heart failure, but the immediate concern in this scenario is addressing the pulmonary edema to ensure adequate gas exchange and oxygenation.
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A public health nurse is addressing the issue of childhood lead poisoning in a low-income community. Which intervention should be prioritized?
- A. Providing free blood lead level testing for children
- B. Distributing pamphlets on the dangers of lead exposure
- C. Conducting home inspections for lead-based paint
- D. Educating parents about lead poisoning prevention
Correct Answer: A
Rationale: Providing free blood lead level testing for children should be prioritized as it directly identifies children who are at risk and in need of intervention. This intervention allows for early detection and timely implementation of necessary measures to prevent further lead exposure or address existing poisoning. Distributing pamphlets (choice B) may raise awareness but does not directly identify at-risk children. Conducting home inspections (choice C) is important but may not be as immediate and targeted as blood lead level testing. Educating parents (choice D) is essential but may not directly identify and address individual cases of lead poisoning as testing does.
During a home visit, the nurse observes that an elderly client has numerous bruises on her arms and appears fearful of her caregiver. What should the nurse do first?
- A. report the findings to adult protective services
- B. ask the client how she got the bruises
- C. document the observations in the client's medical record
- D. discuss the observations with the caregiver
Correct Answer: B
Rationale: The initial step for the nurse should be to ask the client how she got the bruises. This approach allows the nurse to directly assess the situation, gather information from the client, and potentially uncover signs of abuse. Reporting to adult protective services should come after obtaining more details from the client to ensure appropriate action. Documenting the observations is important but should follow gathering information from the client. Discussing the observations with the caregiver may not be appropriate as the caregiver could be the source of abuse, and involving them first may jeopardize the client's safety.
The healthcare professional is planning a health education workshop for a group of adolescents on the dangers of substance abuse. Which strategy is most likely to be effective?
- A. showing videos of the effects of substance abuse
- B. inviting individuals in recovery to share their stories
- C. providing statistical data on substance abuse
- D. distributing brochures on substance abuse prevention
Correct Answer: B
Rationale: Inviting individuals in recovery to share their stories is the most effective strategy for educating adolescents about the dangers of substance abuse. Personal stories have a significant impact as they provide real-life examples of the consequences of substance abuse, making the information more relatable and emotionally engaging. This approach can evoke empathy, create a deeper understanding of the risks involved, and potentially deter adolescents from experimenting with substances. Showing videos of the effects of substance abuse (choice A) may be impactful, but personal narratives often have a stronger emotional connection. Providing statistical data (choice C) may not resonate as strongly with adolescents as personal stories. Distributing brochures (choice D) is informative but may not have the same emotional impact and engagement as hearing firsthand experiences.
The nurse is caring for a client with hyperthyroidism. Which assessment finding requires immediate intervention?
- A. Heart rate of 100 beats per minute.
- B. Blood pressure of 150/90 mm Hg.
- C. Respiratory rate of 24 breaths per minute.
- D. Weight loss of 5 pounds in one week.
Correct Answer: D
Rationale: Weight loss of 5 pounds in one week in a client with hyperthyroidism is concerning as it may indicate severe hypermetabolism, leading to potential complications such as cardiac arrhythmias, muscle weakness, and other metabolic disturbances. Rapid weight loss in hyperthyroidism indicates an accelerated metabolic rate and increased energy expenditure, which can be detrimental to the client's health. The other assessment findings (heart rate of 100 beats per minute, blood pressure of 150/90 mm Hg, respiratory rate of 24 breaths per minute) are commonly seen in clients with hyperthyroidism and may not necessarily require immediate intervention unless they are significantly outside the normal range or causing distress to the client.
When visiting a community health clinic, a client's blood pressure is measured at 146/94. What information should the nurse provide the client?
- A. Participate in an exercise program for 6 weeks
- B. Obtain blood pressure daily for 2 weeks
- C. Increase dietary intake of omega-3 fatty acids
- D. Begin a low sodium diet immediately
Correct Answer: D
Rationale: The correct answer is to advise the client to begin a low sodium diet immediately. High sodium intake can contribute to elevated blood pressure levels. By reducing sodium intake, blood pressure can be effectively lowered. Option A, participating in an exercise program, is beneficial for overall health but may not provide immediate impact on blood pressure. Option B, obtaining blood pressure daily for 2 weeks, may not address the underlying cause or provide immediate intervention. Option C, increasing dietary intake of omega-3 fatty acids, though beneficial for heart health, may not have an immediate impact on lowering blood pressure compared to reducing sodium intake.