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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.
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The nurse is performing the Romberg test on a client during a neurological assessment. Which of the following best describes the rationale for conducting the Romberg test?
- A. To measure respiratory rate and depth
- B. To evaluate coordination and fine motor skills
- C. To test for proprioception and vestibular function
- D. To assess cranial nerve function related to facial expression
Correct Answer: C
Rationale: The Romberg test is performed to assess the client's ability to maintain balance with eyes closed, testing proprioception and vestibular function. Proprioception is the sense of body position, while vestibular function relates to balance and spatial orientation. This test helps to identify sensory ataxia, where proprioceptive input is impaired. By eliminating visual input, the Romberg test challenges the vestibular and proprioceptive systems to maintain balance. Choices A, B, and D are incorrect as they do not relate to the specific purpose of the Romberg test in assessing proprioception and vestibular function.
A nurse is educating nursing students on the importance of client-centered community-based care. The nurse understands that which of the following principles is most essential to client-centered, community-based care in nursing?
- A. Encouraging clients to make decisions without considering their cultural or social background
- B. Ensuring that care plans are tailored to the individual needs and preferences of clients within their community
- C. Focusing primarily on the medical treatment of diseases within a hospital setting
- D. Prioritizing the efficiency of healthcare delivery over patient satisfaction and outcomes
Correct Answer: B
Rationale: Correct Answer: B - Ensuring that care plans are tailored to the individual needs and preferences of clients within their community.
Rationale:
1. Client-centered care emphasizes individuality: By tailoring care plans to individual needs and preferences, nurses show respect for each client's unique circumstances.
2. Community-based care focuses on local resources: By considering the community context, nurses can incorporate resources and support systems specific to the client's environment.
3. Personalized care enhances outcomes: Addressing individual needs leads to better engagement, adherence, and overall health outcomes for clients.
4. Promotes empowerment and autonomy: Involving clients in care planning based on their preferences fosters autonomy and empowers them to actively participate in their own health management.
Summary:
- Choice A neglects the importance of cultural and social backgrounds in decision-making, which are key factors in providing client-centered care.
- Choice C focuses on a hospital setting, not community-based care.
- Choice D prioritizes efficiency over patient satisfaction,
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.
An occupational health nurse in the clinic of an industrial plant is developing a guidebook for clinic workers. Which of the following actions should the nurse include as a secondary prevention strategy?
- A. Organize an influenza immunization campaign
- B. Help plant workers identify signs of carpal tunnel syndrome
- C. Teach plant workers about proper lifting techniques
- D. Collaborate with a physical therapist to develop programs for injured employees to return to work
Correct Answer: B
Rationale: The correct answer is B: Help plant workers identify signs of carpal tunnel syndrome. Carpal tunnel syndrome is a common work-related musculoskeletal disorder that can be prevented or mitigated through early identification and intervention. By educating workers about the signs and symptoms of carpal tunnel syndrome, the nurse can facilitate early detection and prompt treatment, thus serving as a secondary prevention strategy. This proactive approach can help prevent the progression of the condition and reduce the impact on workers' health and productivity.
Other choices are incorrect because:
A: Organizing an influenza immunization campaign is a primary prevention strategy aimed at preventing the occurrence of influenza rather than identifying and managing existing health issues.
C: Teaching proper lifting techniques is a primary prevention strategy to prevent musculoskeletal injuries rather than identifying and managing existing conditions.
D: Collaborating with a physical therapist to develop return-to-work programs is a tertiary prevention strategy focused on rehabilitation and reintegration rather than early identification of health issues.
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.