Nokea
A hospitalized child suddenly has a seizure while his family is visiting. The nurse notes whole body rigidity followed by general jerking movements. The child vomits immediately after the seizure. A priority nursing diagnosis for the child is
- A. High risk for infection related to vomiting
- B. Altered family processes related to chronic illness
- C. Fluid volume deficit related to vomiting
- D. Risk for aspiration related to loss of consciousness
Correct Answer: D
Rationale: Risk for aspiration is a priority concern following a seizure, especially when the child vomits, as there is a danger of aspirating the vomit into the lungs, leading to respiratory complications. The other options are not the priority in this situation. While infection risk and fluid volume deficit are important, ensuring the child's airway is clear and there is no risk of aspiration takes precedence. Altered family processes may be a concern but addressing the immediate physiological risk is the priority.
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The RN is serving on a medical center committee to update goals and protocols based on the national standards. Which goal most directly addresses the Healthy People 2020 initiative?
- A. Reduce ED wait time for indigent clients
- B. Providing transportation for medically challenged clients
- C. Provide access to health services
- D. Refer clients to local health department for medical services
Correct Answer: C
Rationale: The correct answer is C: 'Provide access to health services.' This goal most directly addresses the Healthy People 2020 initiative, which aims to improve health care access for all individuals. Option A, 'Reduce ED wait time for indigent clients,' focuses on efficiency rather than access. Option B, 'Providing transportation for medically challenged clients,' addresses a specific need but does not cover overall health service access. Option D, 'Refer clients to local health department for medical services,' involves referral rather than direct access to services.
Which of the following is a key component of community-based participatory research?
- A. Conducting research in a laboratory setting
- B. Involving community members in the research process
- C. Focusing solely on quantitative data
- D. Ignoring community input
Correct Answer: B
Rationale: The correct answer is B: 'Involving community members in the research process.' Community-based participatory research emphasizes the active involvement of community members in all aspects of the research process, from identifying research questions to interpreting and disseminating results. Choice A is incorrect because community-based participatory research typically takes place in real-world settings, not in laboratories. Choice C is incorrect because community-based participatory research values a mix of quantitative and qualitative data. Choice D is incorrect because community input is essential in this research approach.
A client with terminal cancer is experiencing severe pain. The nurse plans to implement which of the following pain management strategies?
- A. Administer analgesics on a fixed schedule
- B. Administer analgesics only when the client requests
- C. Use non-pharmacological methods only
- D. Increase the dose of analgesics when the client complains of pain
Correct Answer: A
Rationale: Administering analgesics on a fixed schedule is the most appropriate pain management strategy for a client with terminal cancer experiencing severe pain. This approach ensures consistent pain control and helps prevent breakthrough pain. Administering analgesics only when the client requests (Choice B) may lead to uncontrolled pain as the client may delay requesting medication until the pain becomes unbearable. Using non-pharmacological methods only (Choice C) may not provide adequate pain relief for a client experiencing severe pain. Increasing the dose of analgesics when the client complains of pain (Choice D) may result in inconsistent pain control and could lead to potential overdose or adverse effects.
During the care of a client with Legionnaire's disease, which finding would require the nurse's immediate attention?
- A. Pleuritic pain on inspiration
- B. Dry mucus membranes in the mouth
- C. A decrease in respiratory rate from 34 to 24
- D. Decrease in chest wall expansion
Correct Answer: D
Rationale: A decrease in chest wall expansion suggests that the client may be experiencing a serious complication, such as worsening pneumonia or respiratory failure, requiring immediate medical attention. This finding indicates a potential decrease in lung function, which could lead to respiratory distress. Pleuritic pain on inspiration may be related to the disease process but does not indicate an immediate need for intervention. Dry mucus membranes in the mouth may require attention but are not as critical as a decrease in chest wall expansion. A decrease in respiratory rate could be concerning but is not as urgent as a decrease in chest wall expansion, which directly impacts respiratory function.
The community health nurse has been following the care for an adolescent with a history of morbid obesity, asthma, hypertension, and is 22 weeks into a pregnancy. Which of these lab reports sent to the clinic needs to be called to the teen's healthcare provider within the next hour?
- A. Hemoglobin 11 g/dL and calcium 6 mg/dL
- B. Magnesium 0.8 mEq/L and creatinine 3 mg/dL
- C. Blood urea nitrogen 28 mg/dL and glucose 225 mg/dL
- D. Hematocrit 33% and platelets 200,000
Correct Answer: B
Rationale: The correct answer is B. The low magnesium level and elevated creatinine suggest possible renal dysfunction, which is concerning, especially in a pregnant client with multiple risk factors such as morbid obesity, asthma, and hypertension. Immediate attention is needed to address the potential renal issues. The other choices do not indicate such urgent conditions. Hemoglobin and calcium levels in choice A are within acceptable ranges. Choice C shows elevated blood urea nitrogen and glucose levels, which may need monitoring but not immediate attention. Choice D's hematocrit and platelet levels are also within normal ranges and do not indicate an urgent issue.