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a first response team isworking 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 andexhibits manic behavior
- D. a client who has a rigid abdomen with manifestations of shock.
Correct Answer: C
Rationale: The correct answer is C: a client who is ambulatory and exhibits manic behavior. In a triage situation, priority should be given to clients who have the highest risk of deterioration or immediate life-threatening conditions. In this scenario, a client exhibiting manic behavior may be a sign of an underlying medical or psychological emergency that requires immediate attention to prevent harm to themselves or others. This client may be at risk of causing harm or disrupting the triage process, making it necessary to address their condition promptly. Clients with superficial burns, femur fractures with a pedal pulse, or rigid abdomen with shock manifestations are important to assess and treat, but they do not present an immediate threat to themselves or others like a client exhibiting manic behavior.
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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: D
Rationale: The correct answer is D because engaging neighborhood families to monitor the playground for further trash buildup addresses the immediate issue effectively. By involving the community directly, the nurse empowers residents to take ownership of the problem and fosters a sense of responsibility for maintaining a clean environment. This approach promotes sustainable change by creating a culture of vigilance and accountability among families. Other choices such as A, B, and C involve external parties and may not address the root cause or build community capacity for long-term solutions. Therefore, D is the most proactive and community-centered option to promote a clean and safe environment.
a nurse is caring for a client who is homeless. which of the following actions should the nurse take first?
- A. determine the clients understanding of her living situation
- B. assist the client to develop goals for obtaining shelter
- C. discuss the risks of being homeless with the client
- D. develop client teaching using a variety of strategies
Correct Answer: C
Rationale: The correct answer is C: discuss the risks of being homeless with the client. This is the first action the nurse should take because it addresses the immediate health and safety concerns of the client. By discussing the risks associated with homelessness, the nurse can help the client understand the potential dangers and motivate them to seek assistance. Option A focuses on assessing the client's understanding, which can come later once immediate risks are addressed. Option B involves future planning and is not the most urgent priority. Option D involves teaching strategies, which may not be effective if the client is not aware of the risks. Therefore, option C is the most appropriate initial action to ensure the client's immediate well-being.
In the last month three cases of tuberculosis have been referred to the health department. Which of the following is the priority information for the community health nurse to obtain from each client?
- A. Demographics.
- B. Household members.
- C. Occupation.
- D. Health history.
Correct Answer: B
Rationale: The correct answer is B: Household members. This is the priority information because tuberculosis is highly contagious and spreads through close contact. By obtaining information on household members, the nurse can assess the risk of transmission within the household and take appropriate measures to prevent further spread of the disease. Demographics (A) may provide general information but do not directly impact the spread of tuberculosis. Occupation (C) may be relevant for identifying potential exposure sources but household contacts are more immediate. Health history (D) is important but does not address the immediate risk of transmission within the household.
a nurse is counseling a client who is to undergo enzyme linked immunosorbent assay 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: the test measures antibodies to the virus. In enzyme linked immunosorbent assay (ELISA) testing for HIV, antibodies produced by the body in response to the virus are detected. This helps in diagnosing HIV infection. Monitoring disease progression (choice A) requires other tests like viral load testing. Test results are not accurate within 24 hours of exposure (choice C) as it takes time for antibodies to develop. Initiating immunoglobulin administration (choice D) is not necessary for all positive results and depends on the individual's condition.
a community health nurse is providing screening for lipid disorders. which of the following is the primary goal of this activity?
- A. early detection of disease
- B. client enrollment in prevention programs
- C. promotion of appropriate lifestyle changes
- D. identification of family history of medical problems
Correct Answer: A
Rationale: The correct answer is A: early detection of disease. Screening for lipid disorders aims to identify individuals at risk of developing cardiovascular diseases early on. Early detection allows for timely interventions to prevent or manage lipid disorders effectively. Choice B focuses on intervention programs, which come after detection. Choice C emphasizes lifestyle changes, which are secondary to detection. Choice D is about family history, not the primary goal of screening.