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A nurse is caring for a client who is homeless. Which of the following actions should the nurse take first?
- A. Determine the client's understanding of her living situation
- B. Assist the client to develop goals for obtaining shelter
- C. Discuss the risks of being homeless with the client
- D. Develop client teaching using a variety of strategies
Correct Answer: A
Rationale: The correct answer is A: Determine the client's understanding of her living situation. This is the first step because it allows the nurse to assess the client's current situation and needs. Understanding the client's perspective is crucial for providing effective care and support. Assisting the client in developing goals (B) or discussing risks (C) should come after understanding the client's current situation. Developing client teaching (D) is important but should be based on the client's understanding and needs, which is why it comes after assessing their understanding.
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A nurse is working in a shelter following a disaster. Which of the following is the priority action for the nurse to take?
- A. Create diversionary activities for children
- B. Address the physical needs of clients
- C. Help clients gather needed supplies
- D. Explore feelings the clients are experiencing
Correct Answer: B
Rationale: The correct answer is B: Address the physical needs of clients. This is the priority action because in a disaster setting, ensuring the basic physical needs of clients such as food, water, shelter, and medical care takes precedence to ensure their survival and well-being. Without addressing these needs first, the clients' health and safety could be compromised. Creating diversionary activities for children (A), helping clients gather supplies (C), and exploring clients' feelings (D) are important but secondary to addressing immediate physical needs. It is crucial to prioritize basic survival needs before addressing emotional or social needs in a disaster situation.
A faith-based organization asks a community health nurse to develop a mobile meal program for older adults. Which of the following actions should the nurse plan to take first?
- A. Determine potential funding sources for the program
- B. Inquire about the availability of volunteers
- C. Identify alternative solutions to address concerns
- D. Perform a needs assessment
Correct Answer: D
Rationale: The correct answer is D: Perform a needs assessment. This is because conducting a needs assessment is the first crucial step in program planning. It helps the nurse to gather data on the specific needs and preferences of older adults in the community. This data will guide the nurse in developing a mobile meal program that is tailored to meet the actual needs of the target population.
Option A: Determining potential funding sources should come after identifying the specific needs of the population, as funding sources will be based on the program's requirements.
Option B: Inquiring about the availability of volunteers is important but should be considered after understanding the needs of the older adults.
Option C: Identifying alternative solutions is premature without first understanding the actual needs of the population through a needs assessment.
In summary, performing a needs assessment is the first step as it provides essential information to guide the development of an effective and targeted mobile meal program for older adults.
A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?
- A. A client who is receiving heparin for deep-vein thrombosis.
- B. A client who is 1 day postoperative following a vertebroplasty.
- C. A client who has cancer and a sealed implant for radiation therapy.
- D. A client who has COPD and a respiratory rate of 44/min.
Correct Answer: B
Rationale: The correct choice is B: A client who is 1 day postoperative following a vertebroplasty. This client is the most stable among the options provided. Early discharge is appropriate because the client is 1 day postoperative, likely past the critical immediate postoperative period. Discharging this client will create space for incoming emergency admissions. Choice A should not be discharged early as managing deep-vein thrombosis with heparin requires close monitoring to prevent complications. Choice C should not be discharged early due to the need for ongoing cancer treatment. Choice D should not be discharged early as the client with COPD and a high respiratory rate of 44/min requires close monitoring and intervention to prevent respiratory distress.
A clinic nurse is assessing a client who has measles. Which of the following findings should the nurse expect?
- A. Koplik spots inside the mouth
- B. Persistent low-grade temperature
- C. Muscle aches and tenderness
- D. Rash confined to the trunk of the body
Correct Answer: A
Rationale: The correct answer is A: Koplik spots inside the mouth. These are small, white spots surrounded by a red ring that appear on the buccal mucosa. This finding is characteristic of measles and typically precedes the onset of the rash. Koplik spots are highly specific to measles and can aid in early diagnosis. Persistent low-grade temperature (B) and muscle aches and tenderness (C) are common symptoms of many viral illnesses, including measles, but they are not specific to measles. The rash associated with measles typically starts on the face and head before spreading to the trunk and extremities, so a rash confined to the trunk (D) would not be expected in measles.
A community health nurse is caring for a client in a culturally diverse community. Which of the following actions demonstrates accurate cultural knowledge about a specific cultural group?
- A. Touching the hair of an African American client during an assessment
- B. Offering to shake hands when meeting an Asian client of the opposite gender
- C. Maintaining eye contact when interviewing a Native American client
- D. Including both hot and cold food items from a Hispanic client's menu
Correct Answer: D
Rationale: The correct answer is D because it shows respect for the Hispanic client's cultural dietary preferences. In Hispanic culture, hot and cold foods are believed to have different properties that can affect health. By including both options on the menu, the nurse demonstrates understanding and acceptance of this cultural belief. Touching the hair of an African American client (A) can be considered intrusive and disrespectful. Offering to shake hands with an Asian client of the opposite gender (B) may not be culturally appropriate in some Asian cultures due to gender norms. Maintaining eye contact with a Native American client (C) may be perceived as disrespectful as some Native American cultures view direct eye contact as confrontational.