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A community health nurse is providing teaching to a group of clients who have alcohol use disorder. Which of the following findings should the nurse include in the teaching as a manifestation of alcohol withdrawal?
- A. Bradycardia
- B. Hypothermia
- C. Increased appetite
- D. Insomnia
Correct Answer: D
Rationale: The correct answer is D: Insomnia. Alcohol withdrawal commonly presents with symptoms such as difficulty sleeping, restlessness, and anxiety due to the disruption of the central nervous system. Insomnia is a hallmark manifestation of alcohol withdrawal syndrome. Bradycardia (A) is not typically associated with alcohol withdrawal; instead, tachycardia is more common. Hypothermia (B) is rare in alcohol withdrawal, as alcohol tends to cause vasodilation and can lead to increased body temperature. Increased appetite (C) is not a typical symptom of alcohol withdrawal; in fact, decreased appetite or nausea is more common. Therefore, the correct choice is D based on the typical manifestations of alcohol withdrawal.
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A nurse is providing teaching to a client who speaks a different language than the nurse, and an interpreter is present. Which of the following findings should the nurse document to show that the client understands the teaching?
- A. Client smiles at the nurse.
- B. Client asks questions to the interpreter.
- C. Client makes eye contact with the nurse frequently.
- D. Client points to printed resources when the nurse speaks.
Correct Answer: B
Rationale: The correct answer is B: Client asks questions to the interpreter. This indicates that the client is actively engaging with the information being provided, seeking clarification, and demonstrating an understanding of the teaching. Asking questions shows the client is processing the information and trying to make sense of it. Smiling at the nurse (A) may indicate politeness or agreement but does not necessarily reflect comprehension. Making eye contact (C) can show attentiveness but not necessarily understanding. Pointing to printed resources (D) may indicate a desire for more information but doesn't confirm comprehension.
A community health nurse observes the accumulation of garbage at a neighborhood playground. Which of the following actions should the nurse take first to promote a clean and safe environment?
- A. Meet with community members to discuss methods of playground maintenance
- B. Partner city officials with community members to improve the playground condition
- C. Work with local businesses to sponsor more trash receptacles in the playground
- D. Engage neighborhood families to monitor the playground for further trash buildup
Correct Answer: A
Rationale: The correct answer is A: Meet with community members to discuss methods of playground maintenance. This is the first action the nurse should take because it involves engaging the community in addressing the issue collectively. By involving community members in the discussion, the nurse can gather insights, ideas, and support to develop effective strategies for maintaining the playground. This approach fosters community ownership and empowers residents to take responsibility for the cleanliness and safety of the playground.
Other choices are incorrect because:
B: Partnering with city officials may be necessary, but involving the community directly should be the initial step.
C: Working with local businesses to sponsor more trash receptacles may help, but community involvement is crucial for sustainable change.
D: Engaging neighborhood families to monitor the playground is important, but community collaboration is needed to address the root cause of the issue.
A parish nurse is counseling a family following a client's recent diagnosis of heart disease. Which of the following actions should the nurse take first?
- A. Discuss the benefits of eating a well-balanced diet with the client's family
- B. Assist the client and the client's partner with finding an affordable exercise program
- C. Offer to accompany the client and the client's partner during health care provider visits
- D. Ask family members about the impact of the disease on relationships within the family
Correct Answer: D
Rationale: The correct answer is D: Ask family members about the impact of the disease on relationships within the family. This is the first action the nurse should take because understanding the family dynamics and relationships can provide valuable insight into how the diagnosis is affecting everyone involved. By assessing the impact on relationships, the nurse can better tailor interventions to support the entire family unit and address any emotional or communication challenges that may arise.
Option A is incorrect as discussing diet benefits should come after assessing the family dynamics. Option B is incorrect because addressing exercise programs should also come after understanding the family's needs. Option C is incorrect as accompanying to provider visits is important but not the first priority.
A community health nurse is working with a family that is struggling to adapt following the loss of a family member. Which of the following actions should the nurse take first?
- A. Refer the family to a grief support group.
- B. Determine the roles of individual family members.
- C. Encourage the family to assign specific tasks to individual family members.
- D. Assist the family to establish a daily routine.
Correct Answer: B
Rationale: The correct answer is B: Determine the roles of individual family members. This is the first step because understanding the roles within the family will help identify strengths and resources to support them through the grieving process. By determining roles, the nurse can assess each family member's needs and abilities, facilitating targeted interventions. Referral to a grief support group (A) may be beneficial later, but understanding family dynamics comes first. While assigning tasks (C) and establishing a routine (D) are important, they should come after identifying roles to ensure they are tailored to the family's specific needs.
A nurse is assessing a client with hyperemesis gravidarum. Which of the following findings should the nurse expect?
- A. Oliguria
- B. Diplopia
- C. Hypoglycemia
- D. Dizziness
Correct Answer: A
Rationale: The correct answer is A: Oliguria. Hyperemesis gravidarum is severe nausea and vomiting during pregnancy, leading to dehydration and electrolyte imbalances. Oliguria, decreased urine output, is expected due to dehydration. Diplopia (B) and dizziness (D) are not specific to hyperemesis gravidarum. Hypoglycemia (C) may occur due to poor oral intake but is not a defining feature.