Nokea
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.
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A nurse is counseling a client who is to undergo enzyme-linked immunosorbent assay (ELISA) testing for HIV. Which of the following information should the nurse include?
- A. The test monitors progression of the disease
- B. The test measures antibodies to the virus
- C. The test results are accurate 24 hr after exposure to the virus
- D. A positive result requires initiating immunoglobulin administration
Correct Answer: B
Rationale: The correct answer is B because ELISA testing for HIV measures antibodies to the virus, indicating exposure to the virus. This is crucial for diagnosing HIV infection. Choice A is incorrect because ELISA does not monitor disease progression. Choice C is incorrect as it takes weeks, not hours, for accurate results post-exposure. Choice D is incorrect as immunoglobulin administration is not the treatment for a positive HIV result.
A nurse is providing teaching to a 50-year-old female client. Which of the following statements should the nurse include in the teaching?
- A. You should have a complete eye examination every 2 years until the age of 64
- B. You should have your hearing screened every 5 years
- C. You should have your stool tested for blood every other year until the age of 74
- D. You should have your fasting blood glucose level checked every 6 years
Correct Answer: A
Rationale: Correct Answer: A - You should have a complete eye examination every 2 years until the age of 64.
Rationale: Regular eye exams help detect common eye conditions such as glaucoma and cataracts early, especially as people age. The American Academy of Ophthalmology recommends eye exams every 2 years for adults aged 40-64. This statement is important for the client's eye health maintenance.
Summary of other choices:
B: Incorrect - Hearing screenings are typically recommended annually for adults over 50, not every 5 years.
C: Incorrect - Stool tests for blood are usually done every year, not every other year until the age of 74, to screen for colorectal cancer.
D: Incorrect - Fasting blood glucose levels should be checked more frequently, at least every 3 years, for early detection of diabetes.
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 community health nurse is working with a group of homeless veterans who have posttraumatic stress disorder. Which of the following interventions should the nurse implement?
- A. Provide coffee and snacks during the meetings
- B. Avoid discussing the traumatic events experienced by the veterans
- C. Change the meeting sites frequently
- D. Teach the clients to practice deep breathing exercises
Correct Answer: D
Rationale: The correct answer is D: Teach the clients to practice deep breathing exercises. This intervention is appropriate because deep breathing exercises are a proven technique to help manage anxiety and stress, common symptoms of posttraumatic stress disorder. By teaching the veterans this skill, the nurse can empower them to cope with their symptoms effectively. Providing coffee and snacks (A) may be comforting but does not address the core issue. Avoiding discussing traumatic events (B) can hinder the therapeutic process. Changing meeting sites frequently (C) may disrupt the sense of safety and trust.
A 35-year-old client who has a diagnosis of tuberculosis informs the provider's office that she is unable to pay for the treatment. Which of the following actions by the nurse will facilitate obtaining appropriate treatment?
- A. Help the client apply for Medicare
- B. Explore options for alternative therapies
- C. Arrange for medication through local agencies
- D. Send the client to the nearest facility for further evaluation
Correct Answer: C
Rationale: The correct answer is C: Arrange for medication through local agencies. This option addresses the immediate need for treatment by connecting the client with resources that can provide medication for tuberculosis at little to no cost. This ensures that the client can access appropriate treatment despite financial constraints.
Option A (Help the client apply for Medicare) may not be feasible or timely, as the client may not qualify or the application process may take too long. Option B (Explore options for alternative therapies) is not appropriate for a serious infectious disease like tuberculosis that requires specific medical treatment. Option D (Send the client to the nearest facility for further evaluation) does not address the client's inability to pay for treatment and may delay necessary intervention.