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A home health nurse manager is caring for a client who has methicillin-resistant Staphylococcus aureus. Which of the following actions should the nurse take?
- A. Remove fresh flowers from the client's home
- B. Wear a mask when within 3 feet of the client
- C. Encourage the client to use a HEPA filter in the house
- D. Double bag soiled dressing in polyethylene bags
Correct Answer: D
Rationale: The correct answer is D: Double bag soiled dressing in polyethylene bags. This is important to prevent the spread of methicillin-resistant Staphylococcus aureus (MRSA) to others. Double bagging the soiled dressing in polyethylene bags helps contain the bacteria and reduces the risk of transmission.
Choice A: Removing fresh flowers is not directly related to preventing the spread of MRSA.
Choice B: Wearing a mask within 3 feet of the client may not be effective in preventing MRSA transmission.
Choice C: Using a HEPA filter is not specifically targeted at preventing MRSA transmission.
In summary, choice D is correct because it directly addresses the prevention of MRSA transmission, while the other choices are not as directly related to this specific concern.
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A nurse is working with a community health care team to devise strategies for preventing violence in the community. Which of the following interventions is an example of tertiary prevention?
- A. Presenting community education programs about stress management
- B. Developing resources for victims of abuse
- C. Urging community leaders to make nonviolence a priority
- D. Assessing for risk factors of intimate partner abuse during health examinations
Correct Answer: B
Rationale: The correct answer is B: Developing resources for victims of abuse. Tertiary prevention focuses on minimizing the impact of established disease or injury. By providing resources for victims of abuse, the community health care team is helping to support those who have already experienced violence, thus reducing potential long-term consequences. Choices A, C, and D are examples of primary and secondary prevention strategies, which aim to prevent violence before it occurs or identify and intervene early in cases of violence. These interventions are important but do not fall under tertiary prevention.
A client states, 'My life has no meaning right now.' What is the nurse's best response?
- A. Have you been thinking about harming yourself?
- B. How long have you been feeling this way?
- C. Tell me what is going on with you right now.
- D. Do you really think your life has no purpose?
Correct Answer: A
Rationale: The correct answer is A. By asking the client if they have been thinking about harming themselves, the nurse is directly addressing the potential risk of suicide, which is crucial when a client expresses feelings of hopelessness. This question helps assess the client's safety and determine the need for immediate intervention. Choices B, C, and D are not as direct in addressing the potential risk of self-harm and may not provide the necessary urgency in ensuring the client's safety. Asking about self-harm is critical in assessing the severity of the client's distress and ensuring appropriate interventions are implemented promptly.
A nurse is working with a care manager for a client who participates in a health maintenance organization. The nurse should identify that a health maintenance organization provides which of the following payment structures?
- A. The client is participating in a fee-for-service health care insurance program
- B. The provider is paid a fixed sum for the client on a monthly or yearly basis
- C. The client pays the insurer a percentage of the total costs for each service rendered by the provider
- D. The provider bills the client directly for a predetermined percentage of the cost of services
Correct Answer: B
Rationale: The correct answer is B. In a health maintenance organization (HMO), the provider is paid a fixed sum for the client on a monthly or yearly basis. This payment structure incentivizes providers to focus on preventive care and cost-effective treatments. This model aims to keep clients healthy and reduce unnecessary services.
A: Fee-for-service is not characteristic of an HMO.
C: This describes a cost-sharing model, not typical of an HMO.
D: Providers do not bill clients directly in an HMO.
A clinic nurse is assessing a client who has measles. Which of the following findings should the nurse expect?
- A. Koplik spots inside the mouth
- B. Persistent low-grade temperature
- C. Muscle aches and tenderness
- D. Rash confined to the trunk of the body
Correct Answer: A
Rationale: The correct answer is A: Koplik spots inside the mouth. These are small, white spots surrounded by a red ring that appear on the buccal mucosa. This finding is characteristic of measles and typically precedes the onset of the rash. Koplik spots are highly specific to measles and can aid in early diagnosis. Persistent low-grade temperature (B) and muscle aches and tenderness (C) are common symptoms of many viral illnesses, including measles, but they are not specific to measles. The rash associated with measles typically starts on the face and head before spreading to the trunk and extremities, so a rash confined to the trunk (D) would not be expected in measles.
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.