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A nurse is caring for a client who is unconscious. Which of the following actions should the nurse take when providing oral care for the client?
- A. Test for the presence of the client's gag reflex
- B. Place the client in the supine position
- C. Use a firm toothbrush for tooth and gum care
- D. Use 2 gauze-wrapped fingers to hold the mouth open
Correct Answer: A
Rationale: The correct answer is A: Test for the presence of the client's gag reflex. This is important to prevent aspiration during oral care. By testing the gag reflex, the nurse can ensure the client's airway is protected. Placing the client in the supine position (choice B) can increase the risk of aspiration. Using a firm toothbrush (choice C) can damage the delicate tissues in the mouth. Using 2 gauze-wrapped fingers to hold the mouth open (choice D) can increase the risk of injury to the client's oral mucosa.
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The partner of an older adult client who has Alzheimer's disease reports that he is not eating. The client's partner refuses to assist the client with feeding and insists the client feed himself without help. What is the priority action the nurse should take?
- A. Arrange for Meals on Wheels assistance
- B. Determine the client's ability to self-feed
- C. Direct the home health aide to assist with meals
- D. Refer the client's partner to an Alzheimer's support group
Correct Answer: B
Rationale: The correct answer is B: Determine the client's ability to self-feed. This is the priority action because it addresses the immediate concern of the client not eating due to the partner's refusal to assist. By assessing the client's ability to self-feed, the nurse can identify any barriers or challenges the client may be facing, such as physical limitations or cognitive impairments. This assessment will guide the nurse in developing an appropriate plan of care to ensure the client's nutritional needs are met.
The other choices are incorrect because they do not directly address the client's current situation.
A: Meals on Wheels assistance may be helpful but does not address the immediate need for the client to eat.
C: Directing the home health aide to assist assumes the client is willing to accept help, which may not be the case.
D: Referring the client's partner to an Alzheimer's support group is important for long-term support but does not address the immediate issue of the client not eating.
A school nurse is teaching bicycle safety to a group of school-age children. Which of the following statements by a child indicates an understanding of the teaching?
- A. I should walk my bicycle through crosswalks.
- B. I should keep my bicycle far away from the curb.
- C. I should ride my bicycle side-by-side when biking with a friend.
- D. I should ride my bicycle in the opposite direction of the traffic flow.
Correct Answer: A
Rationale: The correct answer is A: "I should walk my bicycle through crosswalks." This statement indicates an understanding of the teaching because it shows awareness of pedestrian rules at crosswalks, emphasizing safety when not riding the bicycle. Walking the bicycle through crosswalks ensures visibility to drivers and prevents accidents.
Summary:
B: Keeping the bicycle far from the curb increases the risk of colliding with vehicles or obstacles.
C: Riding side-by-side is unsafe as it can obstruct traffic and increase the chances of accidents.
D: Riding in the opposite direction of traffic flow is dangerous and against traffic laws, increasing the risk of head-on collisions.
A newly hired occupational health nurse is assessing hazards in the work environment. Which of the following actions will help the nurse detect potential physical hazards?
- A. Survey workers about job-related emotional stress.
- B. Measure the noise levels at various locations in the facility.
- C. Identify industrial toxins that are present in the environment.
Correct Answer: B
Rationale: The correct answer is B: Measure the noise levels at various locations in the facility. This action will help the nurse detect potential physical hazards because excessive noise can lead to hearing damage and other health issues. By measuring noise levels, the nurse can identify areas where noise levels exceed safe limits and implement control measures.
Surveying workers about emotional stress (Choice A) is important for psychological well-being but does not directly address physical hazards. Identifying industrial toxins (Choice C) is important for chemical hazards, not physical hazards related to noise. The other choices are not provided, but measuring noise levels is the most relevant action for detecting physical hazards in this scenario.
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.
A nurse is planning a program about healthy eating at an elementary school where most students select French fries and pizza at lunch every day. Which of the following actions should the nurse plan to take first?
- A. Give positive feedback to students who make appropriate choices.
- B. Help students recognize the value of making healthy food choices.
- C. Provide students with resources about making wise choices independently.
- D. Determine students' motivation to learn about healthy food choices.
Correct Answer: D
Rationale: The correct answer is D: Determine students' motivation to learn about healthy food choices. This is the first step because understanding the students' motivation will help tailor the program effectively. By assessing their motivation, the nurse can identify potential barriers to making healthy choices and address them in the program. Positive feedback (A) and resources (C) are important but should come after understanding motivation. Helping students recognize the value of healthy choices (B) is crucial, but motivation assessment precedes this step.