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 public health nurse is responding to a suspected anthrax exposure at a workplace. Which action should the nurse take?
- A. Alert the family members of coworkers about possible exposure to anthrax
- B. Place the employee under quarantine for 14 days
- C. Refer coworkers who might have been exposed to a provider for prophylactic antibiotics
- D. Instruct the client to wear a mask at work
Correct Answer: C
Rationale: The correct action for the public health nurse is to refer coworkers who might have been exposed to a provider for prophylactic antibiotics (Choice C). This is because prophylactic antibiotics can help prevent the development of anthrax infection after exposure. Alerting family members (Choice A) is unnecessary as the focus should be on the exposed individuals. Quarantine (Choice B) may not be necessary if the individuals receive prophylactic treatment. Instructing the client to wear a mask (Choice D) is not effective in preventing anthrax transmission.
A nurse is planning a program about healthy eating at an elementary school where most students select French fries and pizza at lunch every day. Which of the following actions should the nurse plan to take first?
- A. Give positive feedback to students who make appropriate choices.
- B. Help students recognize the value of making healthy food choices.
- C. Provide students with resources about making wise choices independently.
- D. Determine students' motivation to learn about healthy food choices.
Correct Answer: D
Rationale: The correct answer is D: Determine students' motivation to learn about healthy food choices. This is the first step because understanding the students' motivation will help tailor the program effectively. By assessing their motivation, the nurse can identify potential barriers to making healthy choices and address them in the program. Positive feedback (A) and resources (C) are important but should come after understanding motivation. Helping students recognize the value of healthy choices (B) is crucial, but motivation assessment precedes this step.
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.
A nurse is conducting a community assessment. Which of the following information should the nurse include as part of the windshield survey?
- A. Demographic data
- B. Mortality rate
- C. Informant interviews
- D. Housing quality
Correct Answer: D
Rationale: The correct answer is D: Housing quality. In a windshield survey, the nurse observes the community from a car to assess physical environment, including housing conditions. This information is crucial for identifying health risks and community needs. Demographic data (A) and mortality rates (B) are important but are typically gathered through other means. Informant interviews (C) involve talking to community members, not part of a windshield survey. Other choices (E, F, G) are not relevant to a windshield survey.
A hospice nurse is talking with the partner of a client who is near death. The partner states, 'How will I go on without them? I already feel alone.' Which of the following actions should the nurse take?
- A. Express sympathy to the client's partner.
- B. Ask the client's partner if they need anything.
- C. Hug the client's partner.
- D. Reassure the client's partner that it will get better.
Correct Answer: A
Rationale: Correct Answer: A: Express sympathy to the client's partner.
Rationale: Expressing sympathy acknowledges the partner's emotions, validates their feelings, and shows empathy. It helps the partner feel heard and supported during a difficult time. This action focuses on the partner's emotional needs, offering comfort and understanding.
Summary:
B: Asking if the partner needs anything is helpful but may not address the emotional distress directly.
C: Hugging without consent may not be appropriate and could make the partner uncomfortable.
D: Reassuring without acknowledging the partner's feelings may come across as dismissive and invalidating.