Nokea
A client with a history of alcoholism is admitted with pancreatitis. Which assessment finding is most important for the nurse to report to the healthcare provider?
- A. Nausea and vomiting.
- B. Epigastric pain radiating to the back.
- C. Temperature of 102°F (38.9°C).
- D. Mild jaundice.
Correct Answer: C
Rationale: A temperature of 102°F (38.9°C) is the most important assessment finding to report to the healthcare provider in a client with pancreatitis and a history of alcoholism. Fever in this context can indicate infection, which is a serious complication requiring immediate intervention. Nausea and vomiting (choice A) are common symptoms of pancreatitis but may not require immediate intervention unless severe. Epigastric pain radiating to the back (choice B) is a classic symptom of pancreatitis and should be addressed, but a fever takes precedence. Mild jaundice (choice D) may be present in pancreatitis but is not as urgent as a high temperature signaling possible infection.
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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.
A homeless client with alcohol dependency will be dismissed from the emergency department in 24 hours. The nurse notes that a tuberculin skin test was prescribed by the healthcare provider. What intervention is most important for the nurse to implement prior to discharge?
- A. Identify how the client will follow-up to have the results read
- B. Give the client written information about the tuberculosis test
- C. Determine if the client understands the purpose of the tuberculin test
- D. Explain to the client results should be read between 48 and 72 hours
Correct Answer: A
Rationale: The most important intervention for the nurse to implement prior to the discharge of a homeless client with alcohol dependency who had a tuberculin skin test prescribed is to identify how the client will follow-up to have the results read. This is crucial to ensure proper diagnosis and treatment. Providing written information (Choice B) is helpful but not as critical as ensuring the follow-up plan. Determining if the client understands the purpose of the test (Choice C) is important but not as immediate as ensuring the follow-up plan. Explaining when the results should be read (Choice D) is important, but the priority is to make sure the client has a plan in place for follow-up.
The community health nurse believes that immunization rates in a lower socioeconomic section of the city are probably below the target set by the state health department. What action should the nurse take first to intervene with this health problem?
- A. join a political action group that focuses attention on the issue in the local news media
- B. partner with a local children's hospital in setting up free 'shot' clinics in the neighborhood
- C. review current epidemiological population data that might document a low immunization rate
- D. call a meeting of citizens to inform them of the importance of having their children immunized
Correct Answer: C
Rationale: The most appropriate initial action for the community health nurse to take when addressing low immunization rates in a lower socioeconomic area is to review current epidemiological data. By reviewing this data, the nurse can gather evidence that documents the low immunization rate in the community. This information is crucial to support the need for targeted interventions to increase immunization rates. Choices A, B, and D involve actions that may be important at later stages of intervention but are not the first step. Joining a political action group, partnering with a hospital for clinics, or holding a community meeting are all valuable strategies, but they should be based on evidence obtained from reviewing epidemiological data to ensure targeted and effective interventions.
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.
During a community health fair, the nurse conducts a blood pressure screening for a 60-year-old woman who has a blood pressure of 160/100 mm Hg. What should the nurse do first?
- A. Instruct the client to monitor her blood pressure at home
- B. Refer the client to her healthcare provider for further evaluation
- C. Educate the client on lifestyle changes to reduce blood pressure
- D. Recheck the blood pressure in 15 minutes
Correct Answer: B
Rationale: When encountering a high blood pressure reading at a community health fair, it is essential for the nurse to refer the client to her healthcare provider for further evaluation. This step ensures that the client receives a comprehensive assessment, diagnosis, and appropriate management plan. In this scenario, it is crucial to prioritize professional evaluation over self-monitoring, lifestyle education, or immediate rechecking of the blood pressure. Referral to a healthcare provider allows for timely intervention and ongoing monitoring of the client's blood pressure to prevent potential complications.