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A client who recently returned from international travel presents to the clinic with high fever, chills, headache, and muscular aches. The healthcare provider suspects severe acute respiratory syndrome (SARS). To prevent transmission of the virus to others, which instruction is most important for the nurse to provide?
- A. Wear a N95 respirator mask during direct contact with others.
- B. Cover mouth and turn head when coughing
- C. Use meticulous hand washing technique.
- D. Discard all tissues used during coughing in a biohazard bag.
Correct Answer: A
Rationale: An N95 respirator mask is critical for preventing airborne transmission of SARS, offering superior protection compared to other measures like hand washing or tissue disposal.
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A graduate nursing student requests information, including laboratory findings and chest x-ray results, about all clients with symptoms of HINI influenza A who have been seen during the last month in a community health clinic. Which action should the charge nurse take?
- A. Provide the information for research purposes only.
- B. Ask the student to sign a standard waiver form.
- C. Obtain written authorization from clients to release the information.
- D. Ask if permission has been obtained from the research committee.
Correct Answer: C
Rationale: Obtaining client authorization ensures compliance with privacy laws like HIPAA, protecting client confidentiality.
The parish nurse notes that an older adult client has had a 5 lb (2.3 kg) weight loss since a check-up one month ago. The client has good hygiene, still drives a car, and lives alone. To which agency should the nurse refer this client?
- A. The Senior Citizen Center.
- B. The Social Security Administration office.
- C. The Adult Day Care Center.
- D. The Women, Infant, and Children office.
Correct Answer: A
Rationale: The Senior Citizen Center offers social activities and meal programs that can address potential causes of weight loss, such as isolation or inadequate nutrition, suitable for an independent older adult.
A community health nurse is helping a group of nursing students plan a tertiary prevention program for a local community clinic that serves a majority Hispanic population. Which service project meets the requirement of a tertiary prevention program and would best serve this population?
- A. Teach clients about recommended immunizations for children.
- B. Instruct teens about prevention of sexually transmitted diseases.
- C. Take blood pressures at a local shopping mall in the community.
- D. Demonstrate foot care to a group of clients who have diabetes.
Correct Answer: D
Rationale: Demonstrating foot care for diabetic clients is tertiary prevention, focusing on managing complications of an existing condition, highly relevant for a Hispanic population with a high prevalence of diabetes.
The nurse is documenting the medical history of a young adult client who was recently diagnosed with type 1 diabetes mellitus. The client smokes 2 packs of cigarettes daily and the client's father died of a heart attack at the age of 45. Which annual screening is most important for the nurse include?
- A. Renal insufficiency.
- B. Peripheral neuropathy.
- C. Hyperlipidemia.
- D. Retinopathy.
Correct Answer: C
Rationale: Given the client's smoking habit and family history of early heart attack, screening for hyperlipidemia is critical to address cardiovascular risk, which is heightened by these factors and diabetes.
Community health nurses are particularly concerned with the spread of communicable diseases such as hepatitis A. Which group of Individuals should the nurse identify as being at greatest risk for contracting this type of hepatitis?
- A. Low income families living in cramped quarters.
- B. Sexually active persons with multiple partners.
- C. IV drug users who share needles.
- D. Those who have recently received a blood transfusion.
Correct Answer: A
Rationale: Hepatitis A spreads primarily through the fecal-oral route, often via contaminated food or water. Low-income families in cramped quarters are at higher risk due to increased exposure to unsanitary conditions and poor hygiene practices.