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A nurse is caring for a client who is wearing anti-embolic stockings. Which of the following interventions should the nurse include in the plan of care?
- A. Determine if the stockings are binding
- B. Palpate the distal pulse to the cast
- C. Waits for 2 minutes between suctions
- D. Ask security to detain the client until the provider is notified
Correct Answer: A
Rationale: The correct answer is A: Determine if the stockings are binding. This is important because anti-embolic stockings should not be too tight as it can impede circulation, leading to complications. Palpating the distal pulse to the cast (B) is unrelated to anti-embolic stockings. Waiting for 2 minutes between suctions (C) is not relevant to the care of a client wearing anti-embolic stockings. Asking security to detain the client until the provider is notified (D) is inappropriate and violates the client's rights.
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A nurse is planning a community health program about Parkinson's disease. Which of the following interventions should the nurse include as a tertiary prevention strategy?
- A. Provide daily exercise classes to improve ambulation for clients who have Parkinson's disease.
- B. Provide screenings for community members to identify early manifestations of Parkinson's disease.
- C. Educate clients about common techniques used to diagnose Parkinson's disease.
- D. Educate clients who are at risk for Parkinson's disease about maintaining a low-cholesterol diet.
Correct Answer: A
Rationale: The correct answer is A: Provide daily exercise classes to improve ambulation for clients who have Parkinson's disease. Tertiary prevention aims to prevent complications and further deterioration in individuals already diagnosed with a disease. In Parkinson's disease, exercise is crucial to maintain mobility and function. Regular exercise helps improve balance, strength, and coordination, which can slow down the progression of the disease and enhance quality of life. Providing daily exercise classes specifically tailored to individuals with Parkinson's disease aligns with tertiary prevention goals by promoting physical activity and independence.
Choice B is incorrect as it focuses on early identification rather than intervention for those already diagnosed. Choice C is incorrect as educating about diagnostic techniques is more aligned with secondary prevention. Choice D is incorrect as maintaining a low-cholesterol diet is not a specific tertiary prevention strategy for Parkinson's disease.
Which type of study will the nurse use to understand the experiences of an immigrant group in the community?
- A. Qualitative
- B. Randomized control
- C. Needs assessment
- D. Quality improvement
Correct Answer: A
Rationale: The nurse would use a qualitative study to understand the experiences of an immigrant group because qualitative research focuses on exploring and understanding individuals' experiences, perspectives, and behaviors in-depth. This type of study allows for gathering rich, detailed data through methods like interviews, observations, and focus groups, which are well-suited for capturing the complexities and nuances of immigrant experiences. A randomized control study (B) involves intervention and control groups for causality, not suitable for exploring experiences. Needs assessment (C) focuses on identifying needs and gaps in services. Quality improvement (D) aims to enhance processes and outcomes within a specific setting.
A nurse is counseling a group of clients from a town that was affected by a hurricane 6 months ago. For which of the following clients should the nurse initiate a referral to assess for the presence of posttraumatic stress disorder? (Select all that apply.)
- A. A client who describes feeling disconnected from those around him following the hurricane.
- B. A client who has frequent nightmares about the hurricane.
- C. A client who expresses a realization that life will not return to the way it was before the hurricane.
- D. A client who describes having persistent feelings of anger about the hurricane.
- E. A client who describes having persistent feelings of anger about the hurricane.
Correct Answer: A, B, E
Rationale: The correct answer is A, B, E. Feeling disconnected, having nightmares, and persistent anger are common symptoms of posttraumatic stress disorder (PTSD) following a traumatic event like a hurricane. Referring these clients for further assessment is crucial to determine if they meet the criteria for PTSD diagnosis. Choice C describes a realistic assessment of the situation and does not necessarily indicate PTSD. Choice D, which is repeated, also describes persistent anger, which is a symptom but is already covered by choice E.
A nurse implements an education program that incorporates computer games to reinforce learning for a group of older adults. Although the research demonstrates evidence of improved retention of this information, the nurse experiences exactly the opposite with this group. Which of the following is the most likely cause of such poor outcomes?
- A. Failure to consider client and setting differences
- B. Inadequate incorporation of evidence into practice
- C. Inferior quality of the available research evidence
- D. Lack of skills when evaluating the evidence
Correct Answer: A
Rationale: The correct answer is A: Failure to consider client and setting differences. Older adults may have different learning styles, preferences, and abilities compared to other age groups. The nurse may have overlooked these factors when implementing the computer games, resulting in poor outcomes. This highlights the importance of tailoring educational programs to fit the specific needs of the target audience.
Explanation for incorrect choices:
B: Inadequate incorporation of evidence into practice - This choice suggests a lack of proper implementation of research evidence, which is not directly related to the poor outcomes observed in this scenario.
C: Inferior quality of the available research evidence - The quality of the research evidence does not necessarily explain why the nurse did not achieve the desired outcomes.
D: Lack of skills when evaluating the evidence - While important, the lack of skills in evaluating evidence does not directly address the issue of poor outcomes with older adults in this context.
A nurse in a family practice clinic is screening an adolescent client for idiopathic scoliosis. Which of the following assessments should the nurse perform as part of this screening?
- A. Measure the truncal rotation
- B. Administered 8 u regular insulin sq
- C. Determine if the stockings are binding
- D. Arrange for an ethics committee meeting
Correct Answer: A
Rationale: The correct answer is A: Measure the truncal rotation. When screening for idiopathic scoliosis, assessing truncal rotation is essential as it helps in detecting the presence of spinal curvature. Truncal rotation is a key indicator of scoliosis as the spine rotates along with the curvature. This assessment involves observing the symmetry of the shoulders and scapulae, which can indicate spinal rotation. Therefore, measuring truncal rotation is a crucial step in identifying potential scoliosis in adolescents.
Summary:
B: Administered 8 u regular insulin sq - Irrelevant to scoliosis screening, this is related to diabetes management.
C: Determine if the stockings are binding - Irrelevant to scoliosis screening, this is related to circulation issues.
D: Arrange for an ethics committee meeting - Irrelevant to scoliosis screening, this is related to ethical considerations in healthcare.