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A clinic nurse is assessing a client who has measles. Which of the following findings should the nurse expect?
- A. Koplik spots inside the mouth
- B. Persistent low-grade temperature
- C. Muscle aches and tenderness
- D. Rash confined to the trunk of the body
Correct Answer: A
Rationale: The correct answer is A: Koplik spots inside the mouth. These are small, white spots surrounded by a red ring that appear on the buccal mucosa. This finding is characteristic of measles and typically precedes the onset of the rash. Koplik spots are highly specific to measles and can aid in early diagnosis. Persistent low-grade temperature (B) and muscle aches and tenderness (C) are common symptoms of many viral illnesses, including measles, but they are not specific to measles. The rash associated with measles typically starts on the face and head before spreading to the trunk and extremities, so a rash confined to the trunk (D) would not be expected in measles.
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Several nurses are developing a parish nurse group to help address the primary and secondary health care needs of the congregation. Which of the following services should the nurses plan to provide to the congregation?
- A. Organize an influenza immunization clinic with the American Red Cross
- B. Perform wound care in the home of members
- C. Provide end-of-life care for members who are terminal
- D. Facilitate discharge from the facility to the home
Correct Answer: A
Rationale: The correct answer is A: Organize an influenza immunization clinic with the American Red Cross. This service is important for promoting preventive health measures within the congregation. Influenza immunization helps reduce the spread of flu and protect vulnerable populations such as the elderly and young children. It aligns with the primary and secondary health care needs by focusing on prevention and early intervention. Providing wound care in members' homes (B) is more of a tertiary care service and may require specialized training and resources. End-of-life care (C) and discharge facilitation (D) are also important but may not directly address primary and secondary health care needs in this context.
A home health nurse is assessing a client who has AIDS. Which of the following responses by the client indicates a risk for suicide?
- A. I'm afraid of experiencing pain near the end.
- B. I know that everything will be better soon.
- C. I am relying more and more on my partner for support.
- D. I don't want to lose control of my ability to make decisions.
Correct Answer: B
Rationale: The correct answer is B: "I know that everything will be better soon." This response indicates a risk for suicide as it reflects a sense of hopelessness or feeling that things will not improve. This mindset is often associated with suicidal ideation.
A: Fear of pain near the end is a common concern in terminal illnesses but does not directly indicate suicide risk.
C: Relying on a partner for support can be a coping mechanism and does not necessarily indicate suicide risk.
D: Desire to maintain decision-making control is a sign of autonomy and does not directly indicate suicide risk.
In summary, choice B is correct as it suggests a lack of hope for the future, while the other choices do not directly indicate a risk for suicide.
A home health nurse is visiting a client who had a stroke 2 months ago. Which of the following findings should the nurse report to the interprofessional care team?
- A. The client dresses her affected side first.
- B. The client bears weight on their arms when using crutches.
- C. The client coughs when swallowing her medications.
- D. The client's caregiver fills a pill organizer weekly.
Correct Answer: C
Rationale: The correct answer is C: The client coughs when swallowing her medications. This finding should be reported because coughing when swallowing can indicate dysphagia, a common complication after a stroke that can lead to aspiration pneumonia. Aspiration pneumonia is a serious condition that requires immediate attention to prevent respiratory complications. Reporting this finding to the interprofessional care team allows for prompt assessment and intervention to prevent further complications.
Choices A, B, and D are not as urgent to report to the interprofessional care team. A client dressing their affected side first, bearing weight on arms with crutches, or a caregiver filling a pill organizer weekly do not pose immediate risks to the client's health and do not require immediate intervention from the care team. These findings are important for monitoring the client's progress and adjusting care plans but do not have the same level of urgency as coughing when swallowing medications.
A nurse is caring for a client who is unconscious. Which of the following actions should the nurse take when providing oral care for the client?
- A. Test for the presence of the client's gag reflex
- B. Place the client in the supine position
- C. Use a firm toothbrush for tooth and gum care
- D. Use 2 gauze-wrapped fingers to hold the mouth open
Correct Answer: A
Rationale: The correct answer is A: Test for the presence of the client's gag reflex. This is important to prevent aspiration during oral care. By testing the gag reflex, the nurse can ensure the client's airway is protected. Placing the client in the supine position (choice B) can increase the risk of aspiration. Using a firm toothbrush (choice C) can damage the delicate tissues in the mouth. Using 2 gauze-wrapped fingers to hold the mouth open (choice D) can increase the risk of injury to the client's oral mucosa.
A nurse is serving on a state task force for disaster planning. The nurse is engaging in disaster preparedness efforts when performing which of the following actions?
- A. Implementing a disaster triage plan with a local medical facility
- B. Functioning as a manager at a temporary shelter
- C. Assisting with the identification of a biological agent
- D. Organizing a mass casualty drill for community members
Correct Answer: D
Rationale: The correct answer is D: Organizing a mass casualty drill for community members. This is the correct action for disaster preparedness as it helps in testing response procedures and identifying areas for improvement. Implementing a disaster triage plan (A) is important but doesn't involve community participation. Functioning as a manager at a temporary shelter (B) is a crucial role during a disaster but doesn't directly relate to preparedness efforts. Assisting with the identification of a biological agent (C) is more about response to an ongoing disaster rather than preparedness. Overall, organizing a mass casualty drill involves proactive planning and community involvement, making it the most suitable choice for disaster preparedness efforts.