Nokea
A nurse is caring for a client who is unconscious. Which of the following actions should the nurse take when providing oral care for the client?
- A. Test for the presence of the client's gag reflex
- B. Place the client in the supine position
- C. Use a firm toothbrush for tooth and gum care
- D. Use 2 gauze-wrapped fingers to hold the mouth open
Correct Answer: A
Rationale: The correct answer is A: Test for the presence of the client's gag reflex. This is important to prevent aspiration during oral care. By testing the gag reflex, the nurse can ensure the client's airway is protected. Placing the client in the supine position (choice B) can increase the risk of aspiration. Using a firm toothbrush (choice C) can damage the delicate tissues in the mouth. Using 2 gauze-wrapped fingers to hold the mouth open (choice D) can increase the risk of injury to the client's oral mucosa.
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A nurse is caring for a client who is having difficulty performing activities of daily living. The nurse is functioning in which of the following roles when arranging for an occupational therapist to visit the client?
- A. Administrator
- B. Nurse consultant
- C. Case manager
- D. Clinician
Correct Answer: C
Rationale: The correct answer is C: Case manager. In this scenario, the nurse is functioning as a case manager by coordinating and arranging for the occupational therapist to visit the client. A case manager is responsible for coordinating care services and resources for clients to meet their healthcare needs. A nurse consultant (B) provides expert advice and guidance but does not typically coordinate services like a case manager. An administrator (A) is in charge of managing the overall operations of a healthcare facility. A clinician (D) directly provides healthcare services to clients. In this situation, the nurse is not assuming these roles but rather acting as a case manager to ensure the client receives the necessary occupational therapy services.
A home health nurse is visiting a client who had a stroke 2 months ago. Which of the following findings should the nurse report to the interprofessional care team?
- A. The client dresses her affected side first.
- B. The client bears weight on their arms when using crutches.
- C. The client coughs when swallowing her medications.
- D. The client's caregiver fills a pill organizer weekly.
Correct Answer: C
Rationale: The correct answer is C: The client coughs when swallowing her medications. This finding should be reported because coughing when swallowing can indicate dysphagia, a common complication after a stroke that can lead to aspiration pneumonia. Aspiration pneumonia is a serious condition that requires immediate attention to prevent respiratory complications. Reporting this finding to the interprofessional care team allows for prompt assessment and intervention to prevent further complications.
Choices A, B, and D are not as urgent to report to the interprofessional care team. A client dressing their affected side first, bearing weight on arms with crutches, or a caregiver filling a pill organizer weekly do not pose immediate risks to the client's health and do not require immediate intervention from the care team. These findings are important for monitoring the client's progress and adjusting care plans but do not have the same level of urgency as coughing when swallowing medications.
A community health nurse is working with a family that is struggling to adapt following the loss of a family member. Which of the following actions should the nurse take first?
- A. Refer the family to a grief support group.
- B. Determine the roles of individual family members.
- C. Encourage the family to assign specific tasks to individual family members.
- D. Assist the family to establish a daily routine.
Correct Answer: B
Rationale: The correct answer is B: Determine the roles of individual family members. This is the first step because understanding the roles within the family will help identify strengths and resources to support them through the grieving process. By determining roles, the nurse can assess each family member's needs and abilities, facilitating targeted interventions. Referral to a grief support group (A) may be beneficial later, but understanding family dynamics comes first. While assigning tasks (C) and establishing a routine (D) are important, they should come after identifying roles to ensure they are tailored to the family's specific needs.
A nurse working in an infectious disease clinic is caring for a client who has a new diagnosis of Lyme disease. Which of the following agencies is responsible for voluntarily reporting cases of this disease to the Centers for Disease Control and Prevention?
- A. Office of the Surgeon General
- B. State Department of Health
- C. Hospital infection control department
- D. Local Red Cross chapter
Correct Answer: B
Rationale: The correct answer is B: State Department of Health. The State Department of Health is responsible for voluntarily reporting cases of Lyme disease to the Centers for Disease Control and Prevention (CDC) because they are tasked with monitoring and controlling the spread of infectious diseases within their jurisdiction. They have the mandate to collect and report data on disease outbreaks to the CDC, enabling national surveillance and response efforts. The other choices are incorrect because the Office of the Surgeon General does not have direct jurisdiction over disease reporting, the hospital infection control department focuses on internal infection control measures, and the Local Red Cross chapter is primarily involved in disaster relief and blood services, not disease surveillance.
A community health nurse is providing screening for lipid disorders. Which of the following is the primary goal of this activity?
- A. Early detection of disease
- B. Client enrollment in prevention programs
- C. Promotion of appropriate lifestyle changes
- D. Identification of family history of medical problems
Correct Answer: A
Rationale: The correct answer is A: Early detection of disease. The primary goal of screening for lipid disorders is to identify individuals at risk for developing lipid disorders such as high cholesterol levels. Early detection allows for timely intervention and treatment to prevent complications like heart disease. Choice B is incorrect because enrollment in prevention programs is a secondary outcome of screening, not the primary goal. Choice C is also incorrect as promoting lifestyle changes is a part of the intervention phase, not the primary goal of screening. Choice D is incorrect as identifying family history is important but not the primary goal of screening for lipid disorders.