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A nurse in a family practice clinic is screening an adolescent client for idiopathic scoliosis. Which of the following assessments should the nurse perform as part of this screening?
- A. Measure the truncal rotation
- B. Administered 8 u regular insulin sq
- C. Determine if the stockings are binding
- D. Arrange for an ethics committee meeting
Correct Answer: A
Rationale: The correct answer is A: Measure the truncal rotation. When screening for idiopathic scoliosis, assessing truncal rotation is essential as it helps in detecting the presence of spinal curvature. Truncal rotation is a key indicator of scoliosis as the spine rotates along with the curvature. This assessment involves observing the symmetry of the shoulders and scapulae, which can indicate spinal rotation. Therefore, measuring truncal rotation is a crucial step in identifying potential scoliosis in adolescents.
Summary:
B: Administered 8 u regular insulin sq - Irrelevant to scoliosis screening, this is related to diabetes management.
C: Determine if the stockings are binding - Irrelevant to scoliosis screening, this is related to circulation issues.
D: Arrange for an ethics committee meeting - Irrelevant to scoliosis screening, this is related to ethical considerations in healthcare.
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A nurse in the emergency department is interviewing a client immediately following a sexual assault. Which of the following actions should the nurse take first?
- A. Determine the client's current anxiety level
- B. Evaluating the number of clients presenting with similar diseases
- C. Giving a very informative and engaging presentation
- D. Weighing students to identify those who are overweight
Correct Answer: A
Rationale: The correct answer is A: Determine the client's current anxiety level. This is the first action the nurse should take as it helps assess the immediate emotional well-being of the client. By understanding the client's anxiety level, the nurse can provide appropriate support and interventions to address any distress or trauma experienced. Evaluating the number of clients with similar diseases (B), giving a presentation (C), and weighing students (D) are not relevant or appropriate actions in this situation. The priority is to address the client's emotional needs and ensure their safety and well-being.
The nurse is discussing the importance of evidence-based decision-making (EBDM) with a group of students. Which statement by a student indicates understanding of this process?
- A. "EBDM is a one-step process to make clinical decisions.â€
- B. "EBDM utilizes subjective decision-making.â€
- C. "EBDM uses interventions with replicable results.â€
- D. "EBDM relies on past nursing experiences.â€
Correct Answer: C
Rationale: The correct answer is C: "EBDM uses interventions with replicable results." This statement indicates an understanding of evidence-based decision-making (EBDM) because it highlights the key principle of using interventions that have been proven to produce consistent and replicable results through research and evidence. By basing decisions on interventions with replicable results, healthcare professionals can ensure that their clinical decisions are informed by reliable evidence rather than personal bias or subjective opinions.
Choice A is incorrect because EBDM is a multi-step process that involves gathering evidence, critically appraising it, and applying it to make decisions. Choice B is incorrect as EBDM focuses on objective evidence rather than subjective decision-making. Choice D is incorrect because while past nursing experiences may inform decision-making, EBDM emphasizes the use of current research and evidence to guide practice.
A community health nurse is developing a plan to improve the community's environmental health. Which of the following actions should the nurse take first?
- A. Encourage community involvement in environmental improvement.
- B. Establish a timeframe for environmental improvements.
- C. Request funding from community organizations.
- D. Collect information about the community's environmental status.
Correct Answer: D
Rationale: The correct answer is D - Collect information about the community's environmental status. This is the first step because it allows the nurse to assess the current environmental health issues in the community. By gathering data, the nurse can identify specific problems and prioritize interventions based on evidence. This information will guide the development of an effective plan tailored to address the community's specific needs.
Choice A is incorrect because community involvement should come after assessing the environmental status. Choice B is incorrect as setting a timeframe is premature without understanding the extent of the issues. Choice C is incorrect as funding should be sought once the plan is developed.
The partner tells the nurse that she is able to manage the client’s physical care but she doesn’t want to leave him home alone while she travels for work. Which of the following referrals should the nurse make?
- A. Respite care
- B. Promoting healthy lifestyle behavior choices among the community members
- C. Eliciting the health history of a client presenting with an illness
- D. Establishing screening programs to diagnosis diseases as early as possible
Correct Answer: A
Rationale: The correct answer is A: Respite care. Respite care provides temporary relief to the primary caregiver by offering a safe environment for the client while the partner is away. This ensures the client's well-being and safety in the partner's absence. Other choices are incorrect because B focuses on community health, C involves health history assessment, and D pertains to screening programs which are not relevant to the partner's immediate concern of leaving the client home alone.
Which statement describes the actions of a nurse who follows Nightingale's Environmental Theory?
- A. Identifying strategies to reduce climate change
- B. Encouraging the use of public transportation
- C. Promoting environmental justice for all people
- D. Using the client's environment to assist in recovery
Correct Answer: D
Rationale: The correct answer is D because Nightingale's Environmental Theory emphasizes the importance of the environment in promoting health and recovery. By using the client's environment to assist in recovery, the nurse is applying Nightingale's principles of creating a healing environment. Choices A, B, and C focus on broader environmental issues, which are important but not directly related to Nightingale's theory of nursing. The nurse's primary focus should be on utilizing the immediate environment to support the client's healing process.