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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.
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A nurse is counseling a group of clients from a town that was affected by a hurricane 6 months ago. For which of the following clients should the nurse initiate a referral to assess for the presence of posttraumatic stress disorder? (Select all that apply.)
- A. A client who describes feeling disconnected from those around him following the hurricane.
- B. A client who has frequent nightmares about the hurricane.
- C. A client who expresses a realization that life will not return to the way it was before the hurricane.
- D. A client who describes having persistent feelings of anger about the hurricane.
- E. A client who describes having persistent feelings of anger about the hurricane.
Correct Answer: A, B, E
Rationale: The correct answer is A, B, E. Feeling disconnected, having nightmares, and persistent anger are common symptoms of posttraumatic stress disorder (PTSD) following a traumatic event like a hurricane. Referring these clients for further assessment is crucial to determine if they meet the criteria for PTSD diagnosis. Choice C describes a realistic assessment of the situation and does not necessarily indicate PTSD. Choice D, which is repeated, also describes persistent anger, which is a symptom but is already covered by choice E.
A nurse successfully persuades an obese client to perform a weekly weigh-in at homeusing a digital scale and record the weight in a log. This strategy is an example of:
- A. Telehealth
- B. Health information technology
- C. Personal responsibility for health
- D. Evidenc
Correct Answer: C
Rationale: The correct answer is C, "Personal responsibility for health." This is because by persuading the client to monitor and record their weight at home, the nurse is empowering the client to take ownership of their health and actively participate in managing their weight. This strategy encourages the client to be accountable for their health outcomes and promotes self-care. Option A, "Telehealth," is incorrect because it refers to the delivery of healthcare services through technology, not necessarily personal responsibility. Option B, "Health information technology," is also incorrect as it pertains to the use of technology to manage health information, not about individual responsibility. Option D is cut off, but if it were "Evidence-based practice," it would be incorrect as it does not directly relate to the client's responsibility for their health.
Which type of study will the nurse use to understand the experiences of an immigrant group in the community?
- A. Qualitative
- B. Randomized control
- C. Needs assessment
- D. Quality improvement
Correct Answer: A
Rationale: The nurse would use a qualitative study to understand the experiences of an immigrant group because qualitative research focuses on exploring and understanding individuals' experiences, perspectives, and behaviors in-depth. This type of study allows for gathering rich, detailed data through methods like interviews, observations, and focus groups, which are well-suited for capturing the complexities and nuances of immigrant experiences. A randomized control study (B) involves intervention and control groups for causality, not suitable for exploring experiences. Needs assessment (C) focuses on identifying needs and gaps in services. Quality improvement (D) aims to enhance processes and outcomes within a specific setting.
A school nurse is developing a primary prevention strategy for school-aged children. Which of the following interventions would the nurse most likely implement?
- A. Developing individualized exercise programs for overweight children
- B. Drafting policy for increases in noncompetitive physical activity programs
- C. Monitoring body mass index (BMI) in children to identify elevations before they become difficult to manage
- D. Notifying parents and/or guardians of their child's height–weight scale in comparison with national norms
Correct Answer: B
Rationale: The correct answer is B because drafting policies for increases in noncompetitive physical activity programs aligns with primary prevention strategies. This intervention focuses on promoting overall health and preventing health problems before they occur. This approach targets the entire school population rather than individual children, making it a more effective primary prevention strategy.
Choice A is incorrect as it focuses on individualized interventions rather than population-based prevention. Choice C focuses on early detection rather than prevention. Choice D, while involving parents, does not address primary prevention but rather provides information after the fact.
A nurse is familiar with evidence-based practice (EBP) and wants to implement it into the care of clients. Which of the following would present the biggest challenge?
- A. Assessing one's current practice and accessing evidence-based resources
- B. Convincing administration that EBP is beneficial
- C. Distinguishing EBP from practice based on old standards
- D. Showing clients that EBP will improve their health outcomes
Correct Answer: D
Rationale: The correct answer is D because showing clients that EBP will improve their health outcomes presents the biggest challenge. This is because clients may be resistant to change or skeptical about new approaches. It requires effective communication and education to convince clients of the benefits of EBP. Assessing current practice (A) and accessing resources, convincing administration (B), and distinguishing EBP from old standards (C) are challenges that can be addressed through education and training. In contrast, clients' attitudes and beliefs are harder to change, making option D the most challenging aspect of implementing EBP.