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A client with a spinal cord injury suddenly develops a throbbing headache, nasal congestion, and a blood pressure of 210/110 mm Hg. Which action should the nurse perform first?
- A. Administer a prescribed antihypertensive
- B. Check the client's bladder for distention
- C. Place the client in a supine position
- D. Notify the healthcare provider
Correct Answer: B
Rationale: Symptoms (headache, congestion, BP 210/110) indicate autonomic dysreflexia; checking bladder distention (B) identifies the trigger first. Medication (A) or supine (C) is secondary. Notification (D) follows. B is correct. Rationale: Removing the stimulus (e.g., bladder) halts dysreflexia, a priority per SCI protocols, preventing hypertensive crisis.
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A nurse provides care to clients of a community clinic that serves a large immigrant population. Which intervention reflects primary prevention for this group?
- A. Screening for tuberculosis
- B. Providing vaccinations
- C. Referring clients with hypertension to a specialist
- D. Teaching clients with diabetes foot care
Correct Answer: B
Rationale: Primary prevention stops illness before it starts, vital for immigrants facing unique risks. Providing vaccinations like measles or flu shots builds immunity, preventing outbreaks in a group often under-vaccinated due to access or prior country norms, a top nursing action in clinics. Screening for tuberculosis is secondary, catching disease early, common in immigrant health but not preventive. Referring hypertension cases or teaching diabetic foot care is tertiary, managing existing conditions, not averting onset. Vaccinations align with primary prevention's proactive stance data shows they cut infectious disease rates in such populations addressing environmental and social vulnerabilities. Nursing leverages this to protect community health, ensuring immigrants, often in crowded settings, dodge preventable illnesses, a practical, impactful step for this clinic's focus.
Which of the following statement best describe health policy?
- A. A hospital rule
- B. Rules affecting health care
- C. A patient's choice
- D. A medical procedure
Correct Answer: B
Rationale: Health policy is rules affecting health care (B), per definition e.g., laws on access. Not hospital (A), patient (C), procedure (D) systemic. B best defines policy's governance, making it correct.
Type of respiration that occurs when there is an increase in depth and rate of respiration usually seen in people who engages in strenuous exercise.
- A. Kussmaul's breathing
- B. Eupnea
- C. Hyperpnea
- D. Bradypnea
Correct Answer: C
Rationale: Hyperpnea (C) is increased depth and rate of respiration, common in strenuous exercise, per respiratory terminology. Kussmaul's (A) is deep, rapid breathing in metabolic acidosis, not exercise. Eupnea (B) is normal breathing, and bradypnea (D) is slow. Hyperpnea matches the physiological response to heightened oxygen demand during activity, making C the correct answer based on its specific context.
What stress response can you expect from a patient with blood sugar of 50 mg/dl?
- A. Body will try to decrease the glucose level
- B. There will be a halt in release of sex hormones
- C. Client will appear restless
- D. Blood pressure will increase
Correct Answer: C
Rationale: A blood sugar level of 50 mg/dl indicates hypoglycemia, a stress state triggering the body's fight-or-flight response. The client will appear restless due to the brain's reliance on glucose; low levels cause agitation as a protective mechanism to signal distress. The body attempts to increase glucose via glycogenolysis and gluconeogenesis (opposite of A), so decreasing glucose further is incorrect. Halting sex hormone release (B) occurs in chronic stress, not acute hypoglycemia. Blood pressure may rise (D) due to catecholamine release, but restlessness is the most immediate and observable response in this acute scenario, aligning with early stress symptoms. Thus, C is correct as it directly reflects the patient's presentation during a hypoglycemic crisis.
Which of the following statement best describe cultural competence?
- A. Ignoring client's cultural beliefs
- B. Providing care that respects cultural differences
- C. Forcing client to follow hospital culture
- D. Treating all clients the same way
Correct Answer: B
Rationale: Cultural competence is providing care respecting cultural differences (B), per nursing standards tailoring to beliefs (e.g., diet, rituals). Ignoring (A), forcing (C), or sameness (D) dismiss diversity. B best defines competence as culturally sensitive care, aligning with Purnell's model, making it correct.