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A client who has diabetes mellitus asks a home health nurse to help her adapt some of her traditional cultural foods to fit her meal plan. Which of the following is the first action the nurse should take when assisting this client?
- A. Provide the client with a printed recipe
- B. Observe the client during preparation of traditional foods
- C. Use cookbooks to include traditional foods in meal plans
- D. Explain the diabetes exchange list
Correct Answer: B
Rationale: The correct answer is B. Observing the client during the preparation of traditional foods allows the nurse to understand the client's current cooking practices, ingredients used, and portion sizes. This information is crucial in determining how to modify the traditional foods to fit the client's meal plan. Providing a printed recipe (A) may not consider the client's cultural preferences or cooking methods. Using cookbooks (C) may not align with the client's traditional foods or cooking techniques. Explaining the diabetes exchange list (D) is important but should come after understanding the client's current food habits.
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A nurse is providing education to a group of adolescents who are pregnant and attending high school. Which of the following information should the nurse include in their teaching?
- A. The need for supplemental folic acid is greatest during the third trimester
- B. The incidence of high birth weight infants is higher in adolescent pregnancy
- C. Pregnant adolescents need to gain less weight than adult mothers
- D. Caffeinated beverages should be replaced with caffeine-free beverages
Correct Answer: D
Rationale: The correct answer is D: Caffeinated beverages should be replaced with caffeine-free beverages. Pregnant adolescents should limit their caffeine intake as excessive caffeine can lead to complications during pregnancy. Caffeine can cross the placenta and affect the baby's heart rate and sleep patterns. It is important for pregnant adolescents to switch to caffeine-free beverages to ensure the health and well-being of both the mother and baby.
A: The need for supplemental folic acid is not specific to the third trimester, it is important throughout pregnancy.
B: The incidence of high birth weight infants is not necessarily higher in adolescent pregnancy compared to adult mothers.
C: Pregnant adolescents actually need to gain weight within the recommended range, similar to adult mothers, to support fetal growth and development.
A nurse is serving on a state task force for disaster planning. The nurse is engaging in disaster preparedness efforts when performing which of the following actions?
- A. Implementing a disaster triage plan with a local medical facility
- B. Functioning as a manager at a temporary shelter
- C. Assisting with the identification of a biological agent
- D. Organizing a mass casualty drill for community members
Correct Answer: D
Rationale: The correct answer is D: Organizing a mass casualty drill for community members. This is the correct action for disaster preparedness as it helps in testing response procedures and identifying areas for improvement. Implementing a disaster triage plan (A) is important but doesn't involve community participation. Functioning as a manager at a temporary shelter (B) is a crucial role during a disaster but doesn't directly relate to preparedness efforts. Assisting with the identification of a biological agent (C) is more about response to an ongoing disaster rather than preparedness. Overall, organizing a mass casualty drill involves proactive planning and community involvement, making it the most suitable choice for disaster preparedness efforts.
A community health nurse is working with a group of clients. The nurse practices the ethical principle of distributive justice by performing which of the following tasks?
- A. Keeping a promise to visit a client who is housebound after the delivery of care.
- B. Ensuring that a client who is homeless receives preventive medical care.
- C. Being honest with the parents of a child about the need to report suspected abuse.
- D. Accepting the decision of an older adult client to live alone in her home.
Correct Answer: B
Rationale: The correct answer is B. Distributive justice refers to fair distribution of resources and services to all individuals, with priority given to those in need. By ensuring that a homeless client receives preventive medical care, the nurse is upholding this principle. This action promotes equity and fairness by addressing the health needs of a vulnerable population.
A: Keeping a promise to visit a housebound client is important for maintaining trust and continuity of care, but it does not directly relate to distributive justice.
C: Being honest about reporting suspected abuse is related to ethical duty and integrity, not distributive justice.
D: Accepting an older adult's decision to live alone respects autonomy and independence, but it is not directly tied to distributive justice.
A home health nurse is planning the initial home visit for a client who has dementia and lives with his adult son's family. Which of the following actions should the nurse take first during the visit?
- A. Encourage the family to join a support group
- B. Provide the family with information about respite care
- C. Educate the family regarding the progression of dementia
- D. Engage the family in informal conversation
Correct Answer: D
Rationale: The correct answer is D: Engage the family in informal conversation. This is the first action the nurse should take during the initial visit because building rapport and establishing trust with the family is crucial in the care of a client with dementia. By engaging in informal conversation, the nurse can observe family dynamics, assess the family's understanding of the client's condition, and gather valuable information about the client's daily routine and needs. This lays the foundation for effective communication and collaboration moving forward.
A: Encouraging the family to join a support group can be beneficial but should come after establishing rapport and assessing the family's needs.
B: Providing information about respite care is important, but it is not the priority during the initial visit.
C: Educating the family about the progression of dementia is important, but it should be done after building rapport and assessing their current understanding.
A community health nurse is providing teaching to a group of clients who have alcohol use disorder. Which of the following findings should the nurse include in the teaching as a manifestation of alcohol withdrawal?
- A. Bradycardia
- B. Hypothermia
- C. Increased appetite
- D. Insomnia
Correct Answer: D
Rationale: The correct answer is D: Insomnia. Alcohol withdrawal commonly presents with symptoms such as difficulty sleeping, restlessness, and anxiety due to the disruption of the central nervous system. Insomnia is a hallmark manifestation of alcohol withdrawal syndrome. Bradycardia (A) is not typically associated with alcohol withdrawal; instead, tachycardia is more common. Hypothermia (B) is rare in alcohol withdrawal, as alcohol tends to cause vasodilation and can lead to increased body temperature. Increased appetite (C) is not a typical symptom of alcohol withdrawal; in fact, decreased appetite or nausea is more common. Therefore, the correct choice is D based on the typical manifestations of alcohol withdrawal.