Nokea
A client is suspected of being poisoned and presents with symmetric, descending flaccid paralysis, blurred vision, double vision, and dry mouth. The nurse should consider these findings consistent with which potential bioterrorism agent?
- A. ricin
- B. botulism toxin
- C. sulfur mustard
- D. yersinia pestis
Correct Answer: B
Rationale: The correct answer is B: botulism toxin. The symptoms described, including symmetric, descending flaccid paralysis, blurred vision, double vision, and dry mouth, are classic manifestations of botulism, which is caused by a toxin produced by Clostridium botulinum. This toxin affects the nervous system, leading to muscle weakness and paralysis. Choice A, ricin, typically presents with gastrointestinal symptoms and organ failure. Choice C, sulfur mustard, causes blistering skin and respiratory issues. Choice D, yersinia pestis, is associated with the plague and presents with fever, chills, weakness, and swollen lymph nodes.
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A community health nurse is addressing the issue of domestic violence in the community. Which intervention should be prioritized?
- A. Providing education on the signs of domestic violence
- B. Setting up a support group for survivors
- C. Partnering with local law enforcement to increase patrols
- D. Creating a confidential hotline for reporting abuse
Correct Answer: D
Rationale: Creating a confidential hotline for reporting abuse is the most critical intervention when addressing domestic violence. A hotline offers a safe and confidential way for individuals experiencing abuse to report incidents, seek help, and access support services. This intervention prioritizes immediate safety and support for victims. Providing education on the signs of domestic violence (Choice A) is important for prevention but may not address the urgent needs of individuals currently experiencing abuse. Setting up a support group for survivors (Choice B) is valuable for emotional support but may not reach those who are not yet identified as survivors. Partnering with local law enforcement to increase patrols (Choice C) focuses more on the law enforcement response rather than providing a direct avenue for victims to seek help and support.
An older client requiring total care resides with a family consisting of two daughters who take shifts providing care around-the-clock. During a home visit, the daughters ask the nurse about resources that are available for client care while they attend a scheduled family reunion. Which information is best for the nurse to provide?
- A. propose the family seek assistance for care in the area of the reunion's location
- B. tell the caregivers to consider hiring a private duty nurse during the time away
- C. advise to have a case management evaluation of the client's home environment
- D. suggest social services be contacted to find a respite care facility for the client
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
During a home visit, the nurse observes that a client with limited mobility has difficulty preparing meals. What should the nurse do first?
- A. suggest that the client use a meal delivery service
- B. assist the client in meal planning
- C. refer the client to a dietitian
- D. educate the client on easy-to-prepare healthy meals
Correct Answer: B
Rationale: Assisting the client in meal planning is the most appropriate initial action as it addresses the immediate issue of meal preparation. By helping the client plan meals according to their dietary needs and limitations, the nurse can support the client in maintaining a healthy diet despite limited mobility. While suggesting a meal delivery service (Choice A) may be a viable option, assisting in meal planning allows for more personalized and sustainable solutions. Referring the client to a dietitian (Choice C) may be necessary for specialized nutritional advice but is not the first step in addressing the immediate concern. Educating the client on easy-to-prepare healthy meals (Choice D) could be beneficial, but meal planning is a more comprehensive approach to ensure the client's dietary needs are met consistently.
A client with a history of hypertension is prescribed enalapril (Vasotec). Which statement by the client indicates a need for further teaching?
- A. I will monitor my blood pressure regularly.
- B. I will report any signs of infection to my healthcare provider.
- C. I will avoid using salt substitutes.
- D. I will increase my intake of potassium-rich foods.
Correct Answer: D
Rationale: The correct answer is D. Increasing potassium intake can lead to hyperkalemia, especially in clients taking ACE inhibitors like enalapril. Hyperkalemia is a potential side effect of ACE inhibitors and can be exacerbated by consuming potassium-rich foods. Monitoring blood pressure regularly (A) is important when taking antihypertensive medications. Reporting signs of infection (B) is crucial as ACE inhibitors can lower the immune response. Avoiding salt substitutes (C) is necessary because they may contain potassium chloride, leading to increased potassium levels, which can be harmful in combination with ACE inhibitors.
An 80-year-old client is given morphine sulfate for postoperative pain. Which concomitant medication should the nurse question that poses a potential development of urinary retention in this geriatric client?
- A. Nonsteroidal anti-inflammatory agents.
- B. Antihistamines.
- C. Tricyclic antidepressants.
- D. Antibiotics.
Correct Answer: C
Rationale: The correct answer is C: Tricyclic antidepressants. Drugs with anticholinergic properties, such as tricyclic antidepressants, can exacerbate urinary retention associated with opioids in older clients. Nonsteroidal anti-inflammatory agents (Choice A) do not typically cause urinary retention. Antihistamines (Choice B) may cause urinary retention but are not the primary concern in this scenario. Antibiotics (Choice D) are not associated with an increased risk of urinary retention compared to tricyclic antidepressants.