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In a long term rehabilitation care unit a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television in the assigned room. Further assessment by the nurse reveals excessive sweating, a splotchy rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should do which action next?
- A. Take the client's respirations, blood pressure (BP), temperature and then pupillary responses
- B. Place the client into the bed and administer the ordered PRN analgesic
- C. Check the client for bladder distention and the client's urinary catheter for kinks
- D. Turn the television off and then assist client to use relaxation techniques
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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When designing a home health care program for disabled children, which factor should be considered when assessing reimbursement for services from private insurance companies?
- A. greater access to any healthcare provider
- B. allowance for early discharge
- C. concern for the quality of care
- D. approval by the network healthcare provider
Correct Answer: D
Rationale: When assessing reimbursement for services from private insurance companies, approval by the network healthcare provider is crucial. This approval ensures that the services provided are within the approved network, allowing for reimbursement. Choices A, B, and C are not directly related to the reimbursement process by private insurance companies. While greater access to any healthcare provider, allowance for early discharge, and concern for the quality of care are important considerations when designing a home health care program, they do not specifically impact the reimbursement process from private insurance companies.
BCG vaccine is supplied in:
- A. freeze-dried form in a sealed glass ampule
- B. liquid form in a sealed glass ampule
- C. liquid form in a vial
- D. both 2 and 3
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A home health nurse knows that a 70-year-old male client who is convalescing at home following a hip replacement is at risk for developing decubitus ulcers. Which physical characteristic of aging contributes to such a risk?
- A. 16% increase in overall body fat.
- B. Reduced melanin production.
- C. Thinning of the skin with loss of elasticity.
- D. Calcium loss in the bones.
Correct Answer: C
Rationale: Thinning of the skin with loss of elasticity is the physical characteristic of aging that contributes to an increased risk of developing decubitus ulcers. As individuals age, the skin becomes thinner and loses its elasticity, making it more susceptible to damage from pressure, leading to the formation of pressure ulcers. Choices A, B, and D are incorrect as they do not directly contribute to the development of decubitus ulcers in this context.
An example of individual influences on health status would be:
- A. Cigarette smoking
- B. A parent with adult-onset diabetes
- C. Exposure to toxic substances in the workplace
- D. All of the above
Correct Answer: D
Rationale: The correct answer is 'D' because all the listed factors - cigarette smoking, a parent with adult-onset diabetes, and exposure to toxic substances in the workplace - can individually influence a person's health status. Cigarette smoking directly impacts health by increasing the risk of various diseases. Having a parent with adult-onset diabetes can also influence one's health due to genetic predisposition and lifestyle factors. Exposure to toxic substances in the workplace can lead to health issues. Choices A, B, and C are not mutually exclusive but rather represent different aspects of individual influences on health status, making 'D' the most comprehensive and accurate answer.
The nurse is assessing a client with chronic obstructive pulmonary disease (COPD). Which of the following findings should the nurse expect?
- A. Decreased anteroposterior diameter
- B. Hyperresonance on percussion
- C. Increased breath sounds
- D. Prolonged expiratory phase
Correct Answer: D
Rationale: The correct answer is D: Prolonged expiratory phase. In COPD, there is airflow obstruction leading to difficulty in exhaling air. This results in a prolonged expiratory phase. Choices A, B, and C are incorrect. Decreased anteroposterior diameter is associated with conditions like barrel chest in emphysema, not COPD. Hyperresonance on percussion is typical in conditions like emphysema, not necessarily in COPD. Increased breath sounds are not a typical finding in COPD; instead, diminished breath sounds may be present due to air trapping.