Nokea
The nurse is caring for an older-adult patient admitted with nausea, vomiting, and diarrhea due to food poisoning. Which priority concern will require collaboration with social services?
- A. The electricity was turned off 3 days ago.
- B. The water comes from the county water supply.
- C. A son and family recently moved into the home.
- D. This home is not furnished with a microwave oven.
Correct Answer: A
Rationale: The correct answer is A because the lack of electricity poses a serious risk to the patient's health and safety, affecting the ability to store and prepare food properly, maintain a comfortable temperature, and access medical devices if needed. Collaboration with social services is crucial to address this urgent issue. Choices B, C, and D do not directly impact the patient's immediate health needs and can be addressed at a later time.
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The nurse is providing information regarding safety and accidental poisoning to a grandparent who will be taking custody of a 1-year-old grandchild. Which comment by the grandparent will cause the nurse to intervene?
- A. The number for poison control is 800-222-1222.
- B. Never induce vomiting if my grandchild drinks bleach.
- C. I should call 911 if my grandchild loses consciousness.
- D. If my grandchild eats a plant
- E. I should provide syrup of ipecac.
Correct Answer: D
Rationale: Correct Answer: D - If my grandchild eats a plant.
Rationale:
- Eating some plants can be toxic to a child, so it is important to seek medical help immediately.
- Plants can cause serious harm and even be fatal if ingested.
- The other options emphasize important safety measures: calling poison control, not inducing vomiting, and seeking emergency help if the child loses consciousness.
- Providing syrup of ipecac is outdated and not recommended anymore due to potential risks.
- Calling 911 is crucial in emergencies, but the immediate concern with plants is to seek medical advice first.
A homeless adult patient presents to the emergency department with vital signs: temperature 94.8° F, blood pressure 106/56, apical pulse 58, and respiratory rate 12. Which vital sign should the nurse address immediately?
- A. Respiratory rate
- B. Temperature
- C. Apical pulse
- D. Blood pressure
Correct Answer: B
Rationale: The correct answer is B: Temperature. A temperature of 94.8°F indicates hypothermia, which can be life-threatening and requires immediate attention to prevent further complications. Hypothermia can lead to decreased heart rate and blood pressure, affecting overall perfusion. Addressing the temperature first is crucial to prevent further deterioration. The other vital signs are within normal range and may not pose an immediate threat to the patient's life.
The nurse is presenting an educational session on safety for parents of adolescents. Which information will the nurse include in the teaching session?
- A. Increased aggressiveness and blood spots on clothing may indicate substance abuse.
- B. Increased aggressiveness is an environmental clue that may indicate an adolescent is abusing.
- C. Adolescents need information about the effects of uncoordination on accidents.
- D. Adolescents need to be reminded to use seat belts primarily on long trips.
Correct Answer: A
Rationale: The correct answer is A. Increased aggressiveness and blood spots on clothing are potential signs of substance abuse in adolescents. This is important information for parents to be aware of as it can indicate a serious issue that needs to be addressed promptly.
Choice B is incorrect because it only partially addresses the issue by mentioning aggressiveness but does not include the specific indication of blood spots on clothing related to substance abuse.
Choice C is incorrect as it focuses on uncoordination and accidents, which is not directly related to the signs of substance abuse mentioned in the question.
Choice D is incorrect as it discusses seat belt use, which is important but not the main focus of the educational session on safety for parents of adolescents.
In summary, choice A is the correct answer because it provides crucial information about potential signs of substance abuse in adolescents, which is relevant to the safety concerns of parents.
A nurse is teaching the patient and family about wound care. Which technique will the nurse teach to best prevent transmission of pathogens?
- A. Wash hands
- B. Wash wound
- C. Wear gloves
- D. Wear eye protection
Correct Answer: A
Rationale: The correct answer is A: Wash hands. This technique is crucial in preventing the transmission of pathogens because hands are a common mode of pathogen spread. Washing hands effectively removes pathogens and reduces the risk of infection. Choice B (Wash wound) is important for wound care but not as effective in preventing transmission of pathogens. Choice C (Wear gloves) is important for personal protection but does not address the primary mode of transmission. Choice D (Wear eye protection) is not directly related to preventing transmission through hand hygiene. It is essential to prioritize hand hygiene as the most effective method of preventing the spread of pathogens.
A home health nurse is assessing a family's home after the birth of an infant. A toddler also lives in the home. Which finding will cause the nurse to follow up?
- A. Plastic grocery bags are neatly stored under the counter.
- B. Electric outlets are covered in all rooms.
- C. No bumper pads are in the crib.
- D. Crib slats are 5 cm apart.
Correct Answer: A
Rationale: The correct answer is A because storing plastic grocery bags under the counter poses a suffocation risk to the toddler. Toddlers could access the bags and potentially suffocate if they put a bag over their head. This finding requires immediate follow-up to ensure the safety of the child.
Choice B is incorrect because covering electric outlets is a safety measure for toddlers, not a cause for follow-up. Choice C is also incorrect because not having bumper pads in the crib is actually recommended for safe sleep practices. Choice D is incorrect as well since crib slats being 5 cm apart is within the safety guidelines.