Nokea
A nurse enters the room of a client and discovers the client with new right-sided weakness and slurred speech. Which of the following actions should the nurse take?
- A. Administer thrombolytics
- B. Call for help
- C. Provide the client with water to test the gag reflex
- D. Perform carotid massage
Correct Answer: B
Rationale: The correct action is to call for help (Choice B). This is because the client is displaying signs of a possible stroke, such as right-sided weakness and slurred speech. Time is critical in stroke management, and calling for help immediately can ensure the client receives prompt medical attention, such as a CT scan to confirm the diagnosis and appropriate treatment. Administering thrombolytics (Choice A) should only be done after a confirmed diagnosis to avoid potential harm. Providing water to test the gag reflex (Choice C) and performing carotid massage (Choice D) are not appropriate actions for a suspected stroke and could delay necessary interventions.
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A nurse is caring for a client diagnosed with Trigeminal neuralgia who is suddenly experiencing severe pain on the left side of the face. The nurse identifies which classification of medications is most effective in treating this type of pain?
- A. Analgesics
- B. Antibiotics
- C. Anticonvulsants
- D. Antihistamines
Correct Answer: C
Rationale: The correct answer is C: Anticonvulsants. Trigeminal neuralgia is a neuropathic pain disorder, and anticonvulsants like carbamazepine are the first-line treatment due to their ability to stabilize nerve cell membranes and reduce pain signals. Analgesics (choice A) may not be effective for neuropathic pain. Antibiotics (choice B) are used to treat infections, not neuropathic pain. Antihistamines (choice D) are used for allergies and not indicated for treating trigeminal neuralgia.
The community health nurse is educating new nurses on the spread of infectious diseases. The nurse utilizes which of the following approaches to explain the factors that allow the reproduction and spread of infectious disease?
- A. Epidemiologic triangle
- B. Levels of prevention
- C. Natural history of disease
- D. Health Promotion
Correct Answer: A
Rationale: The correct answer is A: Epidemiologic triangle. This model explains infectious disease spread by considering the interactions between the host, agent, and environment. Host factors include susceptibility to the disease, agent factors refer to the infectious microorganism, and environmental factors influence transmission. This approach helps new nurses understand the complex interplay of factors leading to disease transmission. Choices B, C, and D are incorrect because they do not specifically address the factors involved in the reproduction and spread of infectious diseases. Level of prevention refers to actions taken to prevent disease, natural history of disease focuses on disease progression, and health promotion aims to improve overall health but does not directly explain disease spread.
A nurse is caring for a client brought to the Emergency Department as one of the first victims of a train accident. The nurse assesses the client, noting a respiratory rate of 38, a weak, rapid pulse, and uncontrolled bleeding. Using NATO guidelines, the nurse assigns which priority tag?
- A. Red tag
- B. Black tag
- C. Green tag
- D. Yellow tag
Correct Answer: A
Rationale: The correct answer is A: Red tag. The nurse assigns a red tag based on the assessment findings of a high respiratory rate, weak rapid pulse, and uncontrolled bleeding, indicating a critically injured patient requiring immediate intervention. Red tag signifies priority 1 according to NATO guidelines, indicating the need for immediate life-saving interventions. Other choices are incorrect because Black tag (B) is used for deceased or non-salvageable patients, Green tag (C) for minor injuries, and Yellow tag (D) for delayed or non-urgent care. In this scenario, the patient's critical condition necessitates the assignment of a red tag for prompt and urgent care.
A nurse is determining if a homebound client is eligible for Meals-on-Wheels. Which of the following is the most important factor for the nurse to consider?
- A. The client's level of family support
- B. The client's financial resources
- C. The client's access to transportation
- D. The client's ability to prepare meals
Correct Answer: D
Rationale: The correct answer is D: The client's ability to prepare meals. This is crucial as Meals-on-Wheels provides food delivery for those unable to cook. By assessing the client's meal preparation ability, the nurse can determine if the service is necessary. Choice A may be helpful, but not as critical as the client's own ability. Choice B is important but not the most crucial for Meals-on-Wheels eligibility. Choice C is relevant, but if the client cannot prepare meals, transportation to get food is secondary.
A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client?
- A. A negative-pressure isolation room
- B. A private room
- C. A semi-private room with a client who has pediculosis capitis
- D. A positive-pressure isolation room
Correct Answer: B
Rationale: The correct answer is B: A private room. This is because scabies is transmitted through close skin-to-skin contact, so placing the client in a private room will help prevent the spread of the infestation to others. A negative-pressure isolation room (choice A) is used for airborne infections, not for scabies. Placing the client in a semi-private room with a client who has pediculosis capitis (lice) (choice C) increases the risk of cross-infection. Positive-pressure isolation rooms (choice D) are used to protect immunocompromised clients from airborne pathogens.