Nokea
A home health nurse knows that a 70-year-old male client who is convalescing at home following a hip replacement is at risk for developing decubitus ulcers. Which physical characteristic of aging contributes to such a risk?
- A. 16% increase in overall body fat.
- B. Reduced melanin production.
- C. Thinning of the skin with loss of elasticity.
- D. Calcium loss in the bones.
Correct Answer: C
Rationale: Thinning of the skin with loss of elasticity is the physical characteristic of aging that contributes to an increased risk of developing decubitus ulcers. As individuals age, the skin becomes thinner and loses its elasticity, making it more susceptible to damage from pressure, leading to the formation of pressure ulcers. Choices A, B, and D are incorrect as they do not directly contribute to the development of decubitus ulcers in this context.
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A client with chronic congestive heart failure should be instructed to contact the home health nurse if which finding occurs?
- A. Weight gain of 2 pounds or more in a 48-hour period
- B. Urinating 4 to 5 times a day
- C. A significant decrease in appetite
- D. Appearance of non-pitting ankle edema
Correct Answer: A
Rationale: A rapid weight gain of 2 pounds or more in a 48-hour period may indicate fluid retention and worsening heart failure, requiring prompt medical evaluation and intervention. This finding is crucial in managing chronic congestive heart failure as it signifies a potential exacerbation of the condition. Choices B, C, and D are less concerning in this context. Urinating 4 to 5 times a day is within the normal range for most individuals and may not be directly related to heart failure. A significant decrease in appetite may be due to various factors and might not be an immediate cause for concern in heart failure patients. The appearance of non-pitting ankle edema, although related to heart failure, is a more chronic and less urgent symptom when compared to a rapid weight gain, which requires immediate attention.
The emphasis of community health nursing is on:
- A. treatment of health problems
- B. preventing problems and promoting optimum health
- C. identification and assessment of health problems
- D. illness end of the wellness-illness continuum
Correct Answer: B
Rationale: Community health nursing primarily focuses on preventive measures and promoting overall health within a community. Choice A is incorrect as treatment is not the main emphasis. Choice C is incorrect as identification and assessment are steps that may be involved but not the main focus. Choice D is incorrect as it refers to the illness end rather than the preventive end of the wellness-illness continuum.
In a long term rehabilitation care unit a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television in the assigned room. Further assessment by the nurse reveals excessive sweating, a splotchy rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should do which action next?
- A. Take the client's respirations, blood pressure (BP), temperature and then pupillary responses
- B. Place the client into the bed and administer the ordered PRN analgesic
- C. Check the client for bladder distention and the client's urinary catheter for kinks
- D. Turn the television off and then assist client to use relaxation techniques
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is discussing dietary intake with an adolescent who has acne. The most appropriate statement for the nurse is:
- A. Eat a balanced diet for your age.
- B. Increase your intake of protein and Vitamin A.
- C. Decrease fatty foods from your diet.
- D. Do not use caffeine in any form, including chocolate.
Correct Answer: A
Rationale: The most appropriate advice for an adolescent with acne is to eat a balanced diet for their age. A balanced diet that includes a variety of nutrients is essential for overall health, including skin health. While protein and Vitamin A are important for skin health, focusing solely on increasing these nutrients may not address the overall dietary needs. Similarly, solely decreasing fatty foods or avoiding caffeine may not be the most effective advice for managing acne. Therefore, the best advice is to promote a balanced diet tailored to the adolescent's age.
On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse's initial response should be to
- A. Give the client orientation materials and review the unit rules and regulations
- B. Introduce oneself and accompany the client to their room
- C. Take the client to the day room and introduce them to the other clients
- D. Ask the nursing assistant to get the client's vital signs and complete the admission search
Correct Answer: B
Rationale: In situations where a client is trembling and fearful upon admission to a psychiatric unit, it is essential to prioritize building trust and reducing anxiety. By introducing oneself and accompanying the client to their room, the nurse can establish a therapeutic relationship, provide a sense of security, and address the client's immediate emotional needs. Choices A, C, and D are not the most appropriate initial responses as they do not directly address the client's emotional state or focus on establishing a supportive relationship.