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A client with a head injury is admitted to the hospital. Which finding indicates a need for immediate intervention?
- A. Glasgow Coma Scale (GCS) score of 15.
- B. Pupils are equal and reactive to light.
- C. Client is drowsy but arousable.
- D. Client does not remember the events leading to the injury.
Correct Answer: C
Rationale: In a client with a head injury, being drowsy but still arousable can be a sign of increased intracranial pressure, which necessitates immediate intervention. This presentation may indicate a deterioration in neurological status, requiring prompt assessment and management to prevent further complications. Choices A, B, and D are not indicative of an immediate need for intervention in this scenario. A Glasgow Coma Scale (GCS) score of 15 indicates the highest level of consciousness; pupils being equal and reactive to light suggest intact cranial nerve function, and memory loss about the injury event is common in head injuries and does not necessarily warrant immediate intervention.
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The healthcare professional is preparing to administer a blood transfusion to a client with anemia. Which action is most important to prevent a transfusion reaction?
- A. Check the client's vital signs before starting the transfusion.
- B. Use a blood filter when administering the transfusion.
- C. Verify the blood type and Rh factor with another healthcare professional.
- D. Administer antihistamines before starting the transfusion.
Correct Answer: C
Rationale: Verifying the blood type and Rh factor with another healthcare professional is the most crucial action to prevent a transfusion reaction. Ensuring compatibility between the donor blood and the recipient is essential in preventing adverse reactions such as hemolytic transfusion reactions. Checking vital signs is important for monitoring the client during the transfusion process but does not directly prevent a transfusion reaction. Using a blood filter can help remove clots and debris but does not address the risk of a reaction due to blood type incompatibility. Administering antihistamines before the transfusion is not a standard practice to prevent transfusion reactions related to blood type incompatibility.
The school nurse is conducting an audit of incident reports for adolescent students. Which finding is the best indication that the Healthy People 2020 objectives are being addressed?
- A. the absenteeism rate has increased greatly over the past two years
- B. during the last year fewer firearms were retrieved on school property
- C. the number of requests for pregnancy testing is higher than last year
- D. decline in the number of students enrolled in school during the year
Correct Answer: B
Rationale: The correct answer is B. A decrease in firearms retrieved on school property is a positive indication that the Healthy People 2020 objectives are being addressed. This finding suggests progress in reducing violence and improving safety in schools, which aligns with the goals of promoting overall health and safety among adolescents. Choices A, C, and D do not directly relate to the Healthy People 2020 objectives. Increased absenteeism, higher requests for pregnancy testing, and a decline in student enrollment do not necessarily reflect the specific health and safety goals outlined in Healthy People 2020.
The healthcare professional is developing a safety program for older adults at a senior center. Which topic should the professional prioritize?
- A. medication management
- B. fall prevention
- C. fire safety
- D. emergency preparedness
Correct Answer: B
Rationale: Fall prevention should be prioritized for older adults as falls are a significant cause of injury and hospitalization in this population. Addressing fall prevention measures can help reduce the risk of falls and improve the overall safety and well-being of older adults. Medication management, fire safety, and emergency preparedness are also important topics, but fall prevention takes precedence due to its direct impact on the health and safety of older adults.
A client with a history of hypertension is admitted with a blood pressure of 180/110 mm Hg. Which medication should the nurse prepare to administer?
- A. Atenolol (Tenormin)
- B. Nifedipine (Procardia)
- C. Hydrochlorothiazide (Microzide)
- D. Clonidine (Catapres)
Correct Answer: D
Rationale: In this scenario of severe hypertension (180/110 mm Hg), the nurse should prepare to administer Clonidine (Catapres), which is an antihypertensive medication commonly used to rapidly lower blood pressure in acute situations. Atenolol and Nifedipine are also antihypertensive medications, but Clonidine is more appropriate for immediate blood pressure reduction in this critical situation. Hydrochlorothiazide is a diuretic often used for long-term management of hypertension, not for rapid lowering of severely elevated blood pressure.
A community health nurse is planning an intervention to reduce the incidence of type 2 diabetes in the community. Which strategy is most effective?
- A. Hosting cooking classes on preparing healthy meals
- B. Offering free blood glucose screenings
- C. Distributing pamphlets on diabetes prevention
- D. Organizing a community walking program
Correct Answer: A
Rationale: The most effective strategy to reduce the incidence of type 2 diabetes in the community is hosting cooking classes on preparing healthy meals. This intervention provides practical skills and education that can directly impact dietary habits, leading to a decreased risk of developing type 2 diabetes. Offering free blood glucose screenings (Choice B) may help in early detection but does not address prevention. Distributing pamphlets on diabetes prevention (Choice C) provides information but lacks the interactive and hands-on approach of cooking classes. Organizing a community walking program (Choice D) promotes physical activity, which is beneficial, but dietary changes have a more significant impact on preventing type 2 diabetes.