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A community health nurse is providing information to a group of older clients about measures to decrease the risk of contracting influenza during peak flu season. The nurse should provide which information?
- A. Clients must stay at home and ask a neighbor or family member to run their errands.
- B. It is best to do grocery shopping and other errands early in the morning when crowds are smaller.
- C. Clients should wash their hands frequently and keep hands away from the face, especially during peak flu season.
- D. Drinking eight 8-oz glasses of fluid each day will reduce the risk of contracting influenza.
Correct Answer: C
Rationale: During peak influenza season, older clients should take measures to reduce the risk of contracting the flu. The most effective preventive measure is frequent hand hygiene and refraining from touching the face, as this reduces the transmission of the flu virus. While it is advisable to avoid crowds, the direct action of hand hygiene is more impactful. Doing errands early in the morning when crowds are smaller is a good suggestion to reduce exposure but does not address the direct transmission through hands. Drinking enough fluid daily is important for overall health but does not directly reduce the risk of contracting influenza.
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According to Erik Erikson's developmental theory, which choice is a developmental task of the middle adult?
- A. Redefining self-perception and capacity for intimacy
- B. Making decisions concerning career, marriage, and parenthood
- C. Providing guidance during interactions with his children
- D. Verbalizing readiness to assume parental responsibilities
Correct Answer: C
Rationale: According to Erikson's developmental theory, the primary developmental task of the middle adult is to achieve generativity. Generativity is the willingness to care for and guide others. Middle adults can achieve generativity with their own children or the children of close friends or through guidance in social interactions with the next generation. Providing guidance during interactions with his children aligns with this developmental task. Choices A, B, and D are not specific to the middle adult stage as they are tasks associated with young adults. Redefining self-perception and capacity for intimacy, making decisions concerning career, marriage, and parenthood, and verbalizing readiness to assume parental responsibilities are all developmental tasks of the young adult according to Erikson's theory.
The mother of a toddler asks the nurse when she will know that her child is ready to start toilet training. The nurse tells the mother that which observation is a sign of physical readiness?
- A. The child no longer has temper tantrums.
- B. The child can remove his or her own clothing.
- C. The child has been walking for 2 years.
- D. The child can eat using a fork and knife.
Correct Answer: B
Rationale: Signs of physical readiness for toilet training include the child's ability to remove his or her own clothing. This ability indicates the child has developed the necessary fine motor skills to manage clothing during toilet training. The other choices are incorrect because temper tantrums, walking for a specific period, and using utensils are not indicators of physical readiness for toilet training.
A nurse is assisting with data collection on an older client who will be seen by a physician in a health care clinic. When the nurse asks the client about sexual and reproductive function, the client reports concern about sexual dysfunction. What should be the nurse's next action?
- A. Document the client's concern in the medical record.
- B. Report the client's concern to the health care provider.
- C. Tell the client that sexual dysfunction is not a normal age-related change.
- D. Ask the client about medications he is taking.
Correct Answer: D
Rationale: Sexual dysfunction is not a normal process of aging. The prevalence of chronic illness and medication use is higher among older adults than in the younger population. Illnesses and medications can interfere with the normal sexual function of older men and women. It is crucial to assess the medications the client is taking as they could be contributing to the reported sexual dysfunction. While documenting the concern and informing the healthcare provider are important steps, the immediate priority is to gather information on the medications that could be impacting the client's sexual function. Therefore, the nurse's next action should be to ask the client about the medications he is taking.
A paraplegic client is in the hospital to be treated for an electrolyte imbalance. Which level of care is the client currently receiving?
- A. primary prevention
- B. secondary prevention
- C. tertiary prevention
- D. health promotion
Correct Answer: B
Rationale: The correct answer is B: secondary prevention. The client is currently receiving secondary prevention care. Secondary prevention focuses on early detection of disease, prompt intervention, and health maintenance for clients experiencing health problems. In this case, the electrolyte imbalance is a health problem that requires treatment to prevent further complications. Choices A, C, and D are incorrect because primary prevention is focused on health promotion and specific protections against illness before it occurs, tertiary prevention is aimed at helping rehabilitate clients after the illness is diagnosed and treated, and health promotion is a broader concept that includes activities aimed at improving overall health and well-being rather than targeting a specific health problem like an electrolyte imbalance.
A nurse auscultating the fetal heart rate (FHR) of a pregnant client in the first trimester of pregnancy notes that the FHR is 160 beats/min. With this information, what should be the nurse's next action?
- A. Notify the healthcare provider of the finding.
- B. Document the findings.
- C. Tell the client that the FHR is faster than normal but that it is nothing to be concerned about at this time.
- D. Wait 15 minutes and then recheck the FHR.
Correct Answer: B
Rationale: An FHR of 160 beats/min in the first trimester of pregnancy is within the normal range, which is generally 120 to 160 beats/min. The appropriate action for the nurse in this situation is to document the findings. There is no need to notify the healthcare provider as this is a normal finding. Informing the client that the FHR is faster than normal may cause unnecessary anxiety, as it falls within the expected range. Waiting to recheck the FHR is not necessary since the rate is already within the normal range.