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A 17-year-old unmarried, pregnant client with drug addiction is a high school dropout, homeless, and has a history of past abuse arrives at the clinic for her first prenatal visit. Which findings should the nurse document as health risk factors for the client? (Select all that apply)
- A. age
- B. school dropout
- C. drug addiction
- D. All of the above
Correct Answer: D
Rationale: All these factors - age, school dropout, drug addiction - are significant health risk factors for the client. Being young, a high school dropout, and struggling with drug addiction can lead to various complications during pregnancy, such as poor prenatal outcomes and social challenges. These factors can impact the client's overall health and well-being, highlighting the importance of addressing them during prenatal care.
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The healthcare provider is assessing a client who has just returned from hemodialysis. Which finding requires immediate intervention?
- A. Weight gain of 2 pounds.
- B. Dizziness.
- C. Blood pressure of 150/90 mm Hg.
- D. Heart rate of 88 beats per minute.
Correct Answer: B
Rationale: Dizziness after hemodialysis can indicate hypovolemia, hypotension, or other complications that require immediate intervention to prevent further deterioration or adverse events. Weight gain of 2 pounds may not be immediately concerning post-hemodialysis. A blood pressure of 150/90 mm Hg is slightly elevated but may not require immediate intervention unless accompanied by symptoms. A heart rate of 88 beats per minute falls within the normal range and may not be an immediate cause for concern after hemodialysis.
A community health nurse is applying for a federal grant to support a smoking cessation educational program. In which order should the nurse prioritize these nursing activities? Arrange in order top to bottom.
- A. Determine the target aggregate that will be served by the program
- B. Consider pros and cons of different methods of data gathering
- C. Select and train the data collection personnel
- D. All of the above
Correct Answer: D
Rationale: The correct answer is 'D' - All of the above. The nurse should first determine the target aggregate that will be served by the program to understand the specific population in need. Subsequently, they should consider the pros and cons of different methods of data gathering to ensure the most appropriate data collection strategies are employed. Finally, selecting and training the data collection personnel is essential for the successful implementation of the program. These steps provide a logical progression from identifying the target group to analyzing the collected data. Choices A, B, and C are all crucial steps that must be taken in sequence to effectively develop and implement the smoking cessation educational program.
The client is unable to void, and the plan of care sets an objective for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30 pm. Which client response should the nurse document to indicate a successful outcome?
- A. Drinks adequate fluids.
- B. Void without difficulty.
- C. Feels less thirsty.
- D. Drinks 240 mL of fluid five times during the shift.
Correct Answer: D
Rationale: The correct answer is D. Drinking 240 mL of fluid five times during the shift indicates a fluid intake of 1200 mL, which exceeds the minimum objective of at least 1000 mL. The client meeting or exceeding the fluid intake goal is a clear indicator of a successful outcome. Choices A, B, and C are incorrect because simply drinking adequate fluids, voiding without difficulty, or feeling less thirsty do not directly demonstrate meeting the specific objective of fluid intake set in the care plan.
The healthcare provider is assessing the laboratory results for a client who is admitted with renal failure and osteodystrophy. Which findings are consistent with this client's clinical picture?
- A. Serum potassium of 4.0 mEq/L and total calcium of 9 mg/dL.
- B. White blood cell count of 15,000/mm3.
- C. Serum potassium of 5.5 mEq/L and total calcium of 6 mg/dL.
- D. Hemoglobin of 12 g/dL and phosphorus of 2 mg/dL.
Correct Answer: C
Rationale: In renal failure and osteodystrophy, there is an alteration in serum electrolyte balance. The correct answer is serum potassium of 5.5 mEq/L and total calcium of 6 mg/dL. Renal failure is associated with hyperkalemia (elevated serum potassium) and hypocalcemia (low total calcium levels). Hyperphosphatemia is also commonly seen in renal failure. Choice A is incorrect as it describes normal levels of serum potassium and total calcium. Choice B is unrelated to the client's condition. Choice D is incorrect as it does not reflect the typical electrolyte imbalances seen in renal failure and osteodystrophy.
The public health nurse is preparing to administer flu vaccines at a community center. Which group should the nurse prioritize for vaccination?
- A. children under 5 years old
- B. adults aged 50-65
- C. pregnant women
- D. healthcare workers
Correct Answer: C
Rationale: Pregnant women should be prioritized for flu vaccination as they are at higher risk for complications from the flu. During pregnancy, changes in the immune, heart, and lung functions make pregnant women more susceptible to severe illness from the flu. Vaccinating pregnant women not only protects them but also provides passive immunity to their newborns. Children under 5, adults aged 50-65, and healthcare workers are important groups for vaccination but do not have the same level of increased risk for flu complications as pregnant women.