Nokea
A nurse is assessing a client who reports a severe headache and stiff neck. The nurse's assessment reveals positive Kernig's and Brudzinski's signs. Which of the following actions should the nurse perform first?
- A. Decrease bright lights
- B. Implement droplet precautions
- C. Initiate IV access
- D. Administer antibiotics
Correct Answer: B
Rationale: The correct answer is B: Implement droplet precautions. This is the first action the nurse should take because positive Kernig's and Brudzinski's signs suggest the client may have meningitis, which is highly contagious through respiratory droplets. Implementing droplet precautions will help prevent the spread of the infection to others. Decreasing bright lights (A) may be helpful for the client's comfort but is not the priority. Initiating IV access (C) and administering antibiotics (D) are important interventions but should be done after implementing precautions to prevent transmission of the infection.
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A nursing preceptor is reviewing life expectancy in the twentieth century with a new nurse. The nurse should recognize that which of the following was most responsible for the dramatic increase in life expectancy during the twentieth century?
- A. Use of antibiotics to fight infections
- B. Sanitation and other public health activities
- C. Technology increases in the field of medical laboratory research
- D. Advances in surgical techniques and procedures
Correct Answer: B
Rationale: The correct answer is B: Sanitation and other public health activities. Improved sanitation, clean water supply, and public health initiatives such as vaccination programs played a crucial role in increasing life expectancy in the 20th century. Sanitation helped reduce the spread of infectious diseases, leading to a significant decrease in mortality rates. Public health activities focused on prevention rather than treatment, which had a long-term positive impact on overall population health. Antibiotics (choice A) were important but came later in the century. Technology increases in medical laboratory research (choice C) and advances in surgical techniques (choice D) contributed to healthcare improvements but were not the primary factors behind the dramatic increase in life expectancy.
A nurse is caring for a client receiving rehabilitation for paralysis following a spinal cord injury and diagnosed with reflex incontinence. Which of the following is the highest priority intervention the nurse should include in the plan of care?
- A. Limited fluid intake to prevent incontinence
- B. Administration of antispasmodic medication
- C. Kegel exercises to strengthen the pelvic floor
- D. Regular perineal care to prevent skin breakdown
Correct Answer: D
Rationale: The correct answer is D: Regular perineal care to prevent skin breakdown. This is the highest priority intervention because reflex incontinence can lead to constant urine leakage, increasing the risk of skin breakdown. Regular perineal care helps maintain skin integrity, preventing complications like pressure ulcers. Limited fluid intake (A) is not appropriate as it can lead to dehydration. Antispasmodic medication (B) may help manage muscle spasms but does not address skin breakdown. Kegel exercises (C) are beneficial for stress incontinence, not reflex incontinence.
The public health nurse is assigned to the population of clients in an inner-city community. The nurse identifies which of the following as a priority intervention?
- A. Develop a survey on teen pregnancies
- B. Hold a focus group to discuss immunizations
- C. Perform a windshield survey
- D. Interview the elderly at the senior's center
Correct Answer: C
Rationale: The correct answer is C: Perform a windshield survey. This is the priority intervention because it involves assessing the community's overall health needs and resources by physically observing the environment. It helps in identifying key health issues, resources, and potential areas for intervention. Developing a survey on teen pregnancies (A) may be important but not a priority without assessing the community first. Holding a focus group on immunizations (B) is valuable but may not address the broader health needs of the community. Interviewing the elderly at the senior's center (D) is specific and may not represent the entire community.
A nurse is delegating tasks to assistive personnel. Which of the following should the nurse consider when using one of the five rights of delegation?
- A. The assistive personnel's ability to complete the task without assistance
- B. The assistive personnel's level of experience and competency in performing the task
- C. The assistive personnel's rapport with clients
- D. The assistive personnel's availability at the time of the delegation
Correct Answer: B
Rationale: The correct answer is B: The assistive personnel's level of experience and competency in performing the task. When delegating tasks, the nurse must consider the individual's ability to safely and effectively perform the task. Choosing someone with the appropriate experience and competency minimizes the risk of errors or harm to the patient. Additionally, considering the person's level of experience ensures that they have the necessary skills to handle the task independently. Choices A, C, and D are incorrect as they do not directly address the crucial aspect of competency and experience required for safe delegation.
A nurse is providing care to a client with Myasthenia gravis who has lost 6 kg of weight over the past 2 months. What should the nurse suggest to improve this client's nutritional status?
- A. Restrict drinking fluids before and during meals
- B. Plan medication doses to occur before meals
- C. Increase the amount of fat and carbohydrates in meals
- D. Eat three large meals per day
Correct Answer: B
Rationale: The correct answer is B: Plan medication doses to occur before meals. This is because Myasthenia gravis can cause difficulty swallowing, leading to weight loss. Taking medication before meals can enhance the client's ability to eat by improving muscle strength for swallowing and chewing. Restricting fluids (A) may exacerbate swallowing difficulties. Increasing fat and carbohydrates (C) can lead to weight gain but may not address the swallowing issue. Eating three large meals (D) may be challenging for someone with swallowing difficulties.