A home health nurse is visiting a client who had a stroke 2...

A home health nurse is visiting a client who had a stroke 2 months ago. Which of the following findings should the nurse report to the interprofessional care team?

A. The client dresses her affected side first.
B. The client bears weight on their arms when using crutches.
C. The client coughs when swallowing her medications.
D. The client's caregiver fills a pill organizer weekly.

Correct Answer: C

Rationale: The correct answer is C: The client coughs when swallowing her medications. This finding should be reported because coughing when swallowing can indicate dysphagia, a common complication after a stroke that can lead to aspiration pneumonia. Aspiration pneumonia is a serious condition that requires immediate attention to prevent respiratory complications. Reporting this finding to the interprofessional care team allows for prompt assessment and intervention to prevent further complications.

Choices A, B, and D are not as urgent to report to the interprofessional care team. A client dressing their affected side first, bearing weight on arms with crutches, or a caregiver filling a pill organizer weekly do not pose immediate risks to the client's health and do not require immediate intervention from the care team. These findings are important for monitoring the client's progress and adjusting care plans but do not have the same level of urgency as coughing when swallowing medications.

A school nurse is assessing a child who has been stung by a bee. The child's hand is swelling, and the nurse notes that the child is allergic to insect stings. Which of the following findings should the nurse expect if the child develops anaphylaxis? (SATA)

A. Bradycardia
B. Nausea
C. Hypertension
D. Urticaria
E. Stridor

Correct Answer: B, D, E

Rationale: Correct Answer: B, D, E
Rationale:
1. Nausea: Anaphylaxis can cause gastrointestinal symptoms like nausea due to the release of inflammatory mediators.
2. Urticaria: Anaphylaxis commonly presents with hives (urticaria) as a manifestation of allergic reaction.
3. Stridor: Anaphylaxis can lead to upper airway swelling, causing stridor due to compromised breathing.
Summary of Incorrect Choices:
A. Bradycardia: Anaphylaxis typically causes tachycardia due to the body's response to the allergen.
C. Hypertension: Anaphylaxis usually results in hypotension due to vasodilation and increased vascular permeability.

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. Distributive justice refers to fair distribution of resources and services to all individuals, with priority given to those in need. By ensuring that a homeless client receives preventive medical care, the nurse is upholding this principle. This action promotes equity and fairness by addressing the health needs of a vulnerable population.

A: Keeping a promise to visit a housebound client is important for maintaining trust and continuity of care, but it does not directly relate to distributive justice.
C: Being honest about reporting suspected abuse is related to ethical duty and integrity, not distributive justice.
D: Accepting an older adult's decision to live alone respects autonomy and independence, but it is not directly tied to distributive justice.

A hospice nurse is talking with the partner of a client who is near death. The partner states, 'How will I go on without them? I already feel alone.' Which of the following actions should the nurse take?

A. Express sympathy to the client's partner.
B. Ask the client's partner if they need anything.
C. Hug the client's partner.
D. Reassure the client's partner that it will get better.

Correct Answer: A

Rationale: Correct Answer: A: Express sympathy to the client's partner.

Rationale: Expressing sympathy acknowledges the partner's emotions, validates their feelings, and shows empathy. It helps the partner feel heard and supported during a difficult time. This action focuses on the partner's emotional needs, offering comfort and understanding.

Summary:
B: Asking if the partner needs anything is helpful but may not address the emotional distress directly.
C: Hugging without consent may not be appropriate and could make the partner uncomfortable.
D: Reassuring without acknowledging the partner's feelings may come across as dismissive and invalidating.

A nurse is counseling a client who has a new diagnosis of chlamydia. Which of the following information should the nurse include in the teaching? (Select all that apply)

A. You should avoid sexual contact until therapy is complete
B. Notify anyone with whom you have had sexual contact over the past 2 months
C. You will need to take an antiviral medication for 30 days
D. Once you complete treatment, you will have an acquired immunity against chlamydia
E. You might experience painful urination until the infection has resolved

Correct Answer: A, B, E

Rationale: The correct answers are A, B, and E. A is correct because avoiding sexual contact until therapy is complete helps prevent spreading chlamydia to others. B is correct as notifying sexual contacts allows for their treatment to prevent reinfection. E is correct because painful urination is a common symptom of chlamydia and should be expected until treatment resolves the infection. Choice C is incorrect because chlamydia is a bacterial infection, not a viral one, so antibiotics are used, not antivirals. Choice D is incorrect because completing treatment does not confer immunity against chlamydia; reinfection is possible.

A nurse is discussing short- and long-term goals with a client who has alcohol use disorder and is being admitted to a treatment facility. Which of the following statements is appropriate for the nurse to include in the discussion?

A. You will be taking a once-weekly dose of disulfiram to help control withdrawal symptoms during treatment
B. Remaining physically active will help to minimize drowsiness and chills associated with initial alcohol withdrawal
C. Attending Al-Anon meetings will help you identify a role model to assist you with making needed changes
D. You will begin learning functional skills to replace defense mechanisms and behaviors while in treatment

Correct Answer: D

Rationale: Correct Answer: D: You will begin learning functional skills to replace defense mechanisms and behaviors while in treatment

Rationale: This statement is appropriate because it focuses on the core aspect of treatment for alcohol use disorder, which is addressing maladaptive coping mechanisms with healthier alternatives. By learning functional skills to replace defense mechanisms and behaviors, the client can develop healthier coping strategies and decrease the likelihood of relapse in the long term.

Summary of other choices:
A: Incorrect - Disulfiram is not used to control withdrawal symptoms; it is a deterrent medication to discourage alcohol consumption.
B: Incorrect - Physical activity is beneficial, but it does not directly address the underlying issues of alcohol use disorder.
C: Incorrect - Al-Anon meetings are for family and friends of individuals with substance use disorders, not for the individual seeking treatment.
E, F, G: No information provided.