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A client with a history of seizures is admitted with status epilepticus. Which medication should the nurse prepare to administer?
- A. Phenytoin (Dilantin)
- B. Diazepam (Valium)
- C. Lorazepam (Ativan)
- D. Carbamazepine (Tegretol)
Correct Answer: C
Rationale: In the management of status epilepticus, the initial medication of choice is a benzodiazepine to rapidly terminate the seizure activity. Lorazepam (Ativan) is preferred over Diazepam (Valium) due to its longer duration of action and lower risk of respiratory depression. Phenytoin (Dilantin) and Carbamazepine (Tegretol) are not the first-line agents for the acute treatment of status epilepticus, making them incorrect choices in this scenario.
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A public health nurse is evaluating a program designed to reduce childhood obesity. Which outcome indicates that the program is successful?
- A. increased participation in physical activities
- B. higher attendance at nutrition education sessions
- C. reduced rates of childhood obesity
- D. greater knowledge of healthy eating habits
Correct Answer: C
Rationale: The correct answer is C: reduced rates of childhood obesity. A reduction in childhood obesity rates is a direct indicator that the program is successful in achieving its goal. Increased participation in physical activities (choice A) and higher attendance at nutrition education sessions (choice B) are positive outcomes, but they do not directly measure the program's effectiveness in reducing obesity. Greater knowledge of healthy eating habits (choice D) is important but does not guarantee a decrease in obesity rates. Therefore, the most significant outcome to determine the success of a childhood obesity reduction program is a reduction in obesity rates.
When caring for a client with a tracheostomy, which action should the nurse take first when performing tracheostomy care?
- A. Remove the inner cannula.
- B. Clean the stoma with normal saline.
- C. Change the tracheostomy ties.
- D. Suction the tracheostomy.
Correct Answer: D
Rationale: Suctioning the tracheostomy is the priority action because it ensures a patent airway before proceeding with any other tracheostomy care interventions. This step helps clear secretions and maintain airway patency, which is crucial for the client's respiratory status. Removing the inner cannula, cleaning the stoma, or changing the tracheostomy ties can follow once the airway is clear. Therefore, options A, B, and C are secondary actions compared to suctioning the tracheostomy.
A community health nurse is addressing the issue of substance abuse in the community. Which intervention should be prioritized?
- A. Providing education on the dangers of substance abuse
- B. Setting up a support group for individuals struggling with addiction
- C. Partnering with local law enforcement to reduce drug availability
- D. Creating a confidential hotline for reporting substance abuse
Correct Answer: D
Rationale: Creating a confidential hotline for reporting substance abuse should be prioritized because it offers a safe and accessible way for individuals to seek help and support for their substance abuse issues. This intervention allows individuals to report their concerns anonymously and seek guidance without fear of judgment or repercussions. Providing education on the dangers of substance abuse (Choice A) is important but may not be as immediately impactful as offering a direct avenue for help. Setting up a support group (Choice B) is valuable but may not reach as many individuals or provide the same level of anonymity as a confidential hotline. Partnering with law enforcement (Choice C) is crucial for addressing substance abuse issues from a legal perspective but may not directly address the immediate needs of individuals seeking help.
The healthcare provider is assessing a client who has returned from surgery. Which finding requires immediate intervention?
- A. Heart rate of 90 beats per minute.
- B. Oxygen saturation of 92%.
- C. Temperature of 99°F (37.2°C).
- D. Pain at the surgical site.
Correct Answer: C
Rationale: A temperature of 99°F (37.2°C) in a postoperative client requires immediate intervention as it may indicate the presence of infection. Elevated temperature post-surgery can be a sign of surgical site infection or systemic infection, which can lead to serious complications if not addressed promptly. Monitoring and managing a fever in a postoperative client is crucial to prevent further complications. The other findings, such as a heart rate of 90 beats per minute, oxygen saturation of 92%, and pain at the surgical site, are common postoperative assessments that may not necessarily require immediate intervention unless they are significantly out of normal range or causing severe distress to the client.
The client with congestive heart failure (CHF) is receiving discharge instructions. Which statement by the client indicates a need for further teaching?
- A. I will weigh myself daily and report a weight gain of more than 2 pounds in 24 hours.
- B. I will take my diuretic medication in the morning.
- C. I will call my healthcare provider if I experience increased shortness of breath.
- D. I will drink at least 3 liters of fluid each day.
Correct Answer: D
Rationale: The correct answer is D. Drinking at least 3 liters of fluid each day may be contraindicated for a client with CHF due to the risk of fluid overload. This can exacerbate heart failure symptoms and lead to complications. Options A, B, and C are all appropriate statements that demonstrate understanding of managing CHF and seeking appropriate medical attention when needed.