Nokea
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.
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A faith community nurse is preparing to meet with the family of an adolescent who has leukemia. Which of the following actions should the nurse plan to take?
- A. Focus the discussion on the adolescent's future career plans.
- B. Determine how the adolescent's health has affected family roles.
- C. Ask another family from the same faith congregation to attend the meeting for support.
- D. Direct conversation to the parents to avoid embarrassing the adolescent.
Correct Answer: B
Rationale: The correct answer is B: Determine how the adolescent's health has affected family roles. This is important because the nurse needs to understand the impact of the adolescent's illness on the family dynamics and roles. By assessing this, the nurse can provide appropriate support and resources to help the family cope effectively.
Choice A is incorrect because focusing on the adolescent's future career plans may not address the immediate concerns and emotional needs of the family facing a health crisis.
Choice C is incorrect as involving another family may not be appropriate without the consent of the adolescent and their family.
Choice D is incorrect because directing the conversation solely to the parents may exclude the adolescent from being an active participant in their own care and may not address their unique needs.
A community health nurse is working with a group of clients. The nurse practices the ethical principle of distributive justice by performing which of the following tasks?
- A. Keeping a promise to visit a client who is housebound after the delivery of care.
- B. Ensuring that a client who is homeless receives preventive medical care.
- C. Being honest with the parents of a child about the need to report suspected abuse.
- D. Accepting the decision of an older adult client to live alone in her home.
Correct Answer: B
Rationale: The correct answer is B because distributive justice involves fair distribution of resources and benefits in society. By ensuring that a homeless client receives preventive medical care, the nurse is promoting fairness and equitable access to healthcare services for all individuals, regardless of their social status. This action aligns with the principle of distributive justice by addressing the healthcare needs of a vulnerable population.
Keeping a promise to visit a housebound client (A) demonstrates fidelity rather than distributive justice. Being honest about reporting suspected abuse (C) is related to veracity and duty to protect vulnerable individuals. Accepting the decision of an older adult to live alone (D) is more about respecting autonomy and independence.
A home health nurse is caring for a client who has chemotherapy-induced nausea that has been resistant to relief from pharmacological measures. Which of the following interventions should the nurse initiate? (Select all that apply)
- A. Use seasonings to enhance the flavor of foods
- B. Provide sips of room temperature ginger ale between meals
- C. Maintain the head of the client's bed in an elevated position after eating
- D. Offer 120 ml (4 oz.) of cold 2% milk as a meal replacement
- E. Assist the client in using guided imagery
Correct Answer: B, C, E
Rationale: The correct interventions for the client with chemotherapy-induced nausea are B, C, and E.
B: Providing sips of room temperature ginger ale can help alleviate nausea due to its antiemetic properties.
C: Maintaining the head of the client's bed in an elevated position after eating can prevent acid reflux and reduce nausea.
E: Assisting the client in using guided imagery can help distract from nausea and promote relaxation.
Incorrect choices:
A: Using seasonings may exacerbate nausea in some clients.
D: Offering cold milk as a meal replacement may not be well-tolerated by a nauseated client and could worsen symptoms.
In summary, the correct interventions focus on soothing the stomach, promoting relaxation, and preventing exacerbation of nausea, while the incorrect choices may not directly address the client's symptoms or could potentially worsen them.
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.