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.
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The partner of an older adult client who has Alzheimer's disease reports that he is not eating. The client's partner refuses to assist the client with feeding and insists the client feed himself without help. What is the priority action the nurse should take?
- A. Arrange for Meals on Wheels assistance
- B. Determine the client's ability to self-feed
- C. Direct the home health aide to assist with meals
- D. Refer the client's partner to an Alzheimer's support group
Correct Answer: B
Rationale: The correct answer is B: Determine the client's ability to self-feed. This is the priority action because it addresses the immediate concern of the client not eating due to the partner's refusal to assist. By assessing the client's ability to self-feed, the nurse can identify any barriers or challenges the client may be facing, such as physical limitations or cognitive impairments. This assessment will guide the nurse in developing an appropriate plan of care to ensure the client's nutritional needs are met.
The other choices are incorrect because they do not directly address the client's current situation.
A: Meals on Wheels assistance may be helpful but does not address the immediate need for the client to eat.
C: Directing the home health aide to assist assumes the client is willing to accept help, which may not be the case.
D: Referring the client's partner to an Alzheimer's support group is important for long-term support but does not address the immediate issue of the client not eating.
A newly hired occupational health nurse is assessing hazards in the work environment. Which of the following actions will help the nurse detect potential physical hazards?
- A. Survey workers about job-related emotional stress.
- B. Measure the noise levels at various locations in the facility.
- C. Identify industrial toxins that are present in the environment.
Correct Answer: B
Rationale: The correct answer is B: Measure the noise levels at various locations in the facility. This action will help the nurse detect potential physical hazards because excessive noise can lead to hearing damage and other health issues. By measuring noise levels, the nurse can identify areas where noise levels exceed safe limits and implement control measures.
Surveying workers about emotional stress (Choice A) is important for psychological well-being but does not directly address physical hazards. Identifying industrial toxins (Choice C) is important for chemical hazards, not physical hazards related to noise. The other choices are not provided, but measuring noise levels is the most relevant action for detecting physical hazards in this scenario.
Which of the following statements should the nurse include in teaching about meningococcal meningitis?
- A. Toothbrush should be placed beside the child's bed
- B. Household contacts will receive prophylactic antibiotics
- C. Transmission will be prevented because of herd immunity
- D. The child is most contagious after the rash develops
Correct Answer: B
Rationale: The correct answer is B: Household contacts will receive prophylactic antibiotics. This statement should be included in teaching about meningococcal meningitis because prophylactic antibiotics are recommended for close contacts to prevent the spread of the infection. This is crucial in preventing outbreaks and protecting others who may have been exposed.
A: Placing a toothbrush beside the child's bed is not relevant to preventing the spread of meningococcal meningitis.
C: Transmission prevention through herd immunity is not a reliable method for controlling the spread of meningococcal meningitis.
D: The child is most contagious before the rash develops, not after, making this statement incorrect.
In summary, teaching about prophylactic antibiotics for household contacts is essential in managing meningococcal meningitis, while the other options do not directly address prevention measures.
A community health nurse observes the accumulation of garbage at a neighborhood playground. Which of the following actions should the nurse take first to promote a clean and safe environment?
- A. Meet with community members to discuss methods of playground maintenance
- B. Partner city officials with community members to improve the playground condition
- C. Work with local businesses to sponsor more trash receptacles in the playground
- D. Engage neighborhood families to monitor the playground for further trash buildup
Correct Answer: A
Rationale: The correct answer is A: Meet with community members to discuss methods of playground maintenance. This is the first action the nurse should take because it involves engaging the community in addressing the issue collectively. By involving community members in the discussion, the nurse can gather insights, ideas, and support to develop effective strategies for maintaining the playground. This approach fosters community ownership and empowers residents to take responsibility for the cleanliness and safety of the playground.
Other choices are incorrect because:
B: Partnering with city officials may be necessary, but involving the community directly should be the initial step.
C: Working with local businesses to sponsor more trash receptacles may help, but community involvement is crucial for sustainable change.
D: Engaging neighborhood families to monitor the playground is important, but community collaboration is needed to address the root cause of the issue.
A first response team is working at the location of a bombing incident. A nurse triaging a group of clients should give treatment priority to which of the following clients?
- A. A client who has superficial partial-thickness burn injuries over 5% of his body
- B. A client who has a femur fracture with a 2+ pedal pulse
- C. A client who is ambulatory and exhibits manic behavior
- D. A client who has a rigid abdomen with manifestations of shock
Correct Answer: D
Rationale: The correct answer is D: A client who has a rigid abdomen with manifestations of shock. This client should receive treatment priority because a rigid abdomen can indicate internal bleeding or organ damage, which are life-threatening conditions requiring immediate medical attention to prevent further complications. Manifestations of shock, such as hypotension and tachycardia, also indicate a critical condition that needs urgent intervention to stabilize the client's condition and prevent deterioration.
Choice A is incorrect because superficial partial-thickness burn injuries, although painful and requiring treatment, are not immediately life-threatening compared to internal injuries like in choice D. Choice B is incorrect as a femur fracture with a palpable pedal pulse indicates distal circulation is intact, making it a lower priority compared to the critical condition in choice D. Choice C is incorrect as manic behavior, while concerning, does not pose an immediate threat to the client's life compared to the potentially life-threatening conditions in choice D.