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A nurse is caring for a client who has experienced a hemorrhagic stroke. Which intervention should the nurse prioritize when providing care to the client?
- A. Assisting the client with active range of motion exercises
- B. Maintaining strict bed rest to minimize cerebral blood flow
- C. Monitoring vital signs and neurological status frequently
- D. Administering anticoagulant medications as prescribed
Correct Answer: C
Rationale: The correct answer is C: Monitoring vital signs and neurological status frequently. This is crucial in caring for a client who has experienced a hemorrhagic stroke as it allows for early detection of any changes in condition such as increased intracranial pressure or neurological deterioration. Vital signs provide important information about the client's overall condition, while neurological status assessments help in evaluating brain function and detecting any signs of worsening stroke symptoms. This intervention is essential for prompt intervention and preventing further complications.
Incorrect answers:
A: Assisting the client with active range of motion exercises - This is not a priority in the acute phase of a hemorrhagic stroke as it can potentially worsen the condition.
B: Maintaining strict bed rest to minimize cerebral blood flow - While bed rest is important, strict bed rest may not be necessary, and minimizing cerebral blood flow is not the primary goal.
D: Administering anticoagulant medications as prescribed - Anticoagulants are contraindicated in hemorrhagic strokes as
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A registered nurse (RN) and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the RN delegate to the LPN?SELECT ALL THAT APPLY
- A. Monitoring vital signs of postoperative clients
- B. Administering routine medications to stable clients
- C. Performing wound care on a client with a Stage III pressure ulcer
- D. Developing a teaching plan for a client newly diagnosed with Type II Diabetes
- E. Providing oral care to an unconscious client
Correct Answer: A,B,C,E
Rationale: The correct tasks to delegate to the LPN include monitoring vital signs, administering routine medications, performing wound care, and providing oral care. RNs are responsible for assessing clients, developing care plans, and making critical decisions. LPNs can safely perform tasks that do not require advanced assessment or critical thinking skills. Monitoring vital signs, administering routine medications, performing wound care, and providing oral care are all within the scope of practice for LPNs and do not require the level of expertise or decision-making that an RN would provide. Developing a teaching plan for a newly diagnosed client with Type II Diabetes requires a higher level of education and expertise, making it inappropriate to delegate to an LPN.
The school nurse identifies 12 students with confirmed cases of influenza A. The families of the children are advised to keep the children home for a minimum of 5 to 7 days. Which of the following is an appropriate action by the nurse?
- A. Closing the school for 6 weeks
- B. Education regarding respiratory and hand hygiene
- C. Discipline in the school setting for improper handwashing
- D. Running a mandatory flu clinic
Correct Answer: B
Rationale: Correct Answer: B - Education regarding respiratory and hand hygiene
Rationale:
1. Education on respiratory and hand hygiene is crucial in preventing the spread of influenza.
2. By educating families and students, the nurse empowers them to take proactive measures.
3. Closing the school for 6 weeks is excessive and disrupts education.
4. Discipline for improper handwashing is reactive and may not address the root cause effectively.
5. Running a mandatory flu clinic may help, but education on hygiene is a preventive measure.
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.
The nurse is preparing for an initial home care visit for a client with diabetes. Which action by the nurse is appropriate? SELECT ALL THAT APPLY
- A. Going automatically into the client's bedroom
- B. Thanking the client for arranging a home visit
- C. Arranging mutual future visits
- D. Asking how they are managing at home
- E. Sitting down and discussing with the client and family members
Correct Answer: C,D,E
Rationale: The correct actions (C, D, E) are appropriate for the initial home care visit for a client with diabetes. C is correct because arranging mutual future visits establishes continuity of care. D is correct since asking about home management helps assess the client's self-care abilities. E is essential as it promotes open communication and involvement of the client and family in the care plan. A is incorrect as entering the client's bedroom without permission violates privacy. B is incorrect as it is general politeness and not specific to diabetes care.
Which of the following statements indicate the importance of epidemiology to the community health nurse? SELECT ALL THAT APPLY
- A. Epidemiology interprets legislation in the community
- B. Epidemiology evaluates the effectiveness of nursing interventions
- C. Epidemiology analyzes and examines the root causes of health outcomes
- D. Epidemiology defines the burden of disease and determinants of health
- E. Epidemiology relates to the health status of a population
Correct Answer: B,C,D,E
Rationale: The correct answers are B, C, D, and E. The importance of epidemiology to the community health nurse lies in its ability to evaluate the effectiveness of nursing interventions (B), analyze and examine the root causes of health outcomes (C), define the burden of disease and determinants of health (D), and relate to the health status of a population (E). By evaluating interventions, nurses can ensure they are evidence-based. Analyzing root causes helps in developing targeted interventions. Defining the burden of disease guides resource allocation. Relating to the health status aids in planning and implementing community health programs. Choices A, F, and G are incorrect as epidemiology does not primarily focus on interpreting legislation or other unrelated aspects.