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A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure (ICP)?
- A. Hypertension
- B. Tinnitus
- C. Hypotension
- D. Tachycardia
Correct Answer: A
Rationale: The correct answer is A: Hypertension. Increased ICP can lead to hypertension due to the body's compensatory mechanisms trying to maintain cerebral perfusion pressure. Hypertension helps to ensure an adequate blood flow to the brain despite the increased pressure. Tinnitus (B) is not typically associated with increased ICP. Hypotension (C) is more likely to occur in cases of shock or hypovolemia. Tachycardia (D) may be present in response to increased ICP, but hypertension is a more specific manifestation of increased intracranial pressure.
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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 community health nurse is educating new nurses on the spread of infectious diseases. The nurse utilizes which of the following approaches to explain the factors that allow the reproduction and spread of infectious disease?
- A. Epidemiologic triangle
- B. Levels of prevention
- C. Natural history of disease
- D. Health Promotion
Correct Answer: A
Rationale: The correct answer is A: Epidemiologic triangle. This model explains infectious disease spread by considering the interactions between the host, agent, and environment. Host factors include susceptibility to the disease, agent factors refer to the infectious microorganism, and environmental factors influence transmission. This approach helps new nurses understand the complex interplay of factors leading to disease transmission. Choices B, C, and D are incorrect because they do not specifically address the factors involved in the reproduction and spread of infectious diseases. Level of prevention refers to actions taken to prevent disease, natural history of disease focuses on disease progression, and health promotion aims to improve overall health but does not directly explain disease spread.
A nurse is caring for a client brought to the Emergency Department as one of the first victims of a train accident. The nurse assesses the client, noting a respiratory rate of 38, a weak, rapid pulse, and uncontrolled bleeding. Using NATO guidelines, the nurse assigns which priority tag?
- A. Red tag
- B. Black tag
- C. Green tag
- D. Yellow tag
Correct Answer: A
Rationale: The correct answer is A: Red tag. The nurse assigns a red tag based on the assessment findings of a high respiratory rate, weak rapid pulse, and uncontrolled bleeding, indicating a critically injured patient requiring immediate intervention. Red tag signifies priority 1 according to NATO guidelines, indicating the need for immediate life-saving interventions. Other choices are incorrect because Black tag (B) is used for deceased or non-salvageable patients, Green tag (C) for minor injuries, and Yellow tag (D) for delayed or non-urgent care. In this scenario, the patient's critical condition necessitates the assignment of a red tag for prompt and urgent care.
A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client?
- A. A negative-pressure isolation room
- B. A private room
- C. A semi-private room with a client who has pediculosis capitis
- D. A positive-pressure isolation room
Correct Answer: B
Rationale: The correct answer is B: A private room. This is because scabies is transmitted through close skin-to-skin contact, so placing the client in a private room will help prevent the spread of the infestation to others. A negative-pressure isolation room (choice A) is used for airborne infections, not for scabies. Placing the client in a semi-private room with a client who has pediculosis capitis (lice) (choice C) increases the risk of cross-infection. Positive-pressure isolation rooms (choice D) are used to protect immunocompromised clients from airborne pathogens.
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.