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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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.
A client who has active tuberculosis (TB) is admitted to the medical unit. What action is most important for the nurse to implement?
- A. Wear a gown and gloves.
- B. Have the client wear a mask.
- C. Perform hand hygiene.
- D. Assign the client to a negative air-flow room.
Correct Answer: D
Rationale: The correct answer is to assign the client to a negative air-flow room (Choice D). Active tuberculosis requires implementation of airborne precautions, including isolating the client in a negative pressure air-flow room to prevent the spread of the infection to others. Choice A (Wear a gown and gloves) is important for standard precautions but does not address the specific airborne precautions needed for tuberculosis. Choice B (Have the client wear a mask) may help reduce the spread of respiratory droplets but does not provide adequate protection for healthcare workers or other patients. Choice C (Perform hand hygiene) is essential for infection control but is not the most critical action when dealing with an airborne infection like tuberculosis.
The nurse is designing a community health project based on a report provided by the World Health Organization that describes healthcare problems in the United States. Which healthcare issue should the nurse give the highest priority when planning the project?
- A. overuse of diagnostic technology
- B. government-based health insurance
- C. the neonatal and infant mortality rates
- D. number of people without access to healthcare
Correct Answer: D
Rationale: The correct answer is D: number of people without access to healthcare. Ensuring access to healthcare is fundamental to addressing a wide range of health issues and is a priority for improving overall community health. Option A, overuse of diagnostic technology, though important, is not the highest priority when considering basic access to healthcare. Option B, government-based health insurance, is relevant but may not directly address the issue of lack of access for all individuals. Option C, neonatal and infant mortality rates, is crucial but addressing access to healthcare for all individuals is a more immediate and foundational concern for the community health project.
The healthcare provider is caring for a client with diabetes insipidus. Which finding indicates that the treatment is effective?
- A. Urine output is decreased.
- B. Thirst is decreased.
- C. Weight loss is observed.
- D. Urine specific gravity is within the normal range.
Correct Answer: D
Rationale: In diabetes insipidus, the body loses excessive amounts of water, leading to diluted urine with low specific gravity. Therefore, when the urine specific gravity is within the normal range, it indicates that the kidneys are properly concentrating urine, which is a sign of effective treatment for diabetes insipidus. Choices A, B, and C are incorrect because in diabetes insipidus, there is polyuria (excessive urination), persistent thirst due to fluid loss, and potential weight loss due to fluid imbalance, so these findings would not indicate effective treatment.
A nurse has started a group for senior citizens in a church setting. The group decides that their first project will be to begin a program for home-bound members. Which program outcome is the best measure of the project's effectiveness?
- A. number of home-bound seniors who are visited
- B. number of church members who are over 65
- C. average annual income for the homebound members
- D. calls received showing interest in the program
Correct Answer: A
Rationale: The number of home-bound seniors visited is the best measure of the project's effectiveness as it directly reflects the reach and impact of the program. Choice B is incorrect as it does not directly relate to the effectiveness of the program for home-bound seniors. Choice C is irrelevant as the average annual income of home-bound members is not a direct measure of the program's effectiveness. Choice D, calls showing interest, is not as direct a measure as the actual visits to the home-bound seniors.