Nokea
A community health nurse is planning an educational program for a group of women who are postmenopausal. Which of the following outcomes is appropriate for this program?
- A. Clients will schedule bone density screening
- B. Clients will arrange for mammograms every 3 years
- C. Clients will start hormone replacement therapy
- D. Clients will significantly decrease caloric intake
Correct Answer: A
Rationale: The correct answer is A: Clients will schedule bone density screening. This outcome is appropriate because postmenopausal women are at increased risk for osteoporosis, making bone density screening crucial for early detection and prevention. It is a proactive measure to assess bone health and reduce the risk of fractures.
Explanation for why other choices are incorrect:
B: Clients will arrange for mammograms every 3 years - While mammograms are important for breast cancer screening, the focus of this program is on postmenopausal women's specific health needs related to bone health.
C: Clients will start hormone replacement therapy - Hormone replacement therapy has risks and benefits and should be individualized based on a woman's specific health history and needs. It is not a universal recommendation for all postmenopausal women.
D: Clients will significantly decrease caloric intake - Caloric intake is important for overall health, but the specific focus of this program is on bone health and screening, not weight management.
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A nurse is caring for a client who is having difficulty performing activities of daily living. The nurse is functioning in which of the following roles when arranging for an occupational therapist to visit the client?
- A. Administrator
- B. Nurse consultant
- C. Case manager
- D. Clinician
Correct Answer: C
Rationale: The correct answer is C: Case manager. In this scenario, the nurse is functioning as a case manager by coordinating and arranging for the occupational therapist to visit the client. A case manager is responsible for coordinating care services and resources for clients to meet their healthcare needs. A nurse consultant (B) provides expert advice and guidance but does not typically coordinate services like a case manager. An administrator (A) is in charge of managing the overall operations of a healthcare facility. A clinician (D) directly provides healthcare services to clients. In this situation, the nurse is not assuming these roles but rather acting as a case manager to ensure the client receives the necessary occupational therapy services.
A first response team is working at the location of a bombing incident. A nurse triaging a group of clients should give treatment priority to which of the following clients?
- A. A client who has superficial partial-thickness burn injuries over 5% of his body
- B. A client who has a femur fracture with a 2+ pedal pulse
- C. A client who is ambulatory and exhibits manic behavior
- D. A client who has a rigid abdomen with manifestations of shock
Correct Answer: D
Rationale: The correct answer is D: A client who has a rigid abdomen with manifestations of shock. This client should receive treatment priority because a rigid abdomen can indicate internal bleeding or organ damage, which are life-threatening conditions requiring immediate medical attention to prevent further complications. Manifestations of shock, such as hypotension and tachycardia, also indicate a critical condition that needs urgent intervention to stabilize the client's condition and prevent deterioration.
Choice A is incorrect because superficial partial-thickness burn injuries, although painful and requiring treatment, are not immediately life-threatening compared to internal injuries like in choice D. Choice B is incorrect as a femur fracture with a palpable pedal pulse indicates distal circulation is intact, making it a lower priority compared to the critical condition in choice D. Choice C is incorrect as manic behavior, while concerning, does not pose an immediate threat to the client's life compared to the potentially life-threatening conditions in choice D.
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 scheduled for a first-time visit to a client. Which of the following should the nurse perform first?
- A. Blood pressure screening
- B. Mental status examination
- C. Review of the neighborhood
- D. Family history
Correct Answer: C
Rationale: The correct answer is C: Review of the neighborhood. This should be performed first to assess the safety and environment of the client's home, ensuring the nurse's safety and the ability to provide care effectively. It helps identify potential hazards or resources in the community. Blood pressure screening (A) can wait until after ensuring a safe environment. Mental status examination (B) is important but can be conducted after assessing the neighborhood. Family history (D) is not a priority for the first visit.
A nurse of a community clinic is preparing an educational guide about cultural variances in expression of pain. Which of the following information should the nurse include?
- A. Middle Eastern cultural practices include hiding pain from close family members
- B. Native American cultural practices include being outspoken about pain
- C. Puerto Rican cultural practices include the view that outspoken expressions of pain are shameful
- D. Chinese cultural practices include enduring pain to prevent family dishonor
Correct Answer: D
Rationale: The correct answer is D: Chinese cultural practices include enduring pain to prevent family dishonor. In Chinese culture, there is a strong emphasis on family honor and saving face. Expressing pain openly may be viewed as a sign of weakness and may bring shame to the family. Therefore, individuals may choose to endure pain silently to avoid dishonoring their family.
Explanation for other choices:
A: Middle Eastern cultural practices include hiding pain from close family members - This is not necessarily a common practice in Middle Eastern cultures and may not accurately represent the diverse ways pain is expressed.
B: Native American cultural practices include being outspoken about pain - While some Native American cultures may value openness about pain, it is not a universal practice among all tribes and communities.
C: Puerto Rican cultural practices include the view that outspoken expressions of pain are shameful - While there may be individuals within Puerto Rican culture who hold this belief, it is not a widely recognized cultural practice.