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A nurse is providing care to a client with Myasthenia gravis who has lost 6 kg of weight over the past 2 months. What should the nurse suggest to improve this client's nutritional status?
- A. Restrict drinking fluids before and during meals
- B. Plan medication doses to occur before meals
- C. Increase the amount of fat and carbohydrates in meals
- D. Eat three large meals per day
Correct Answer: B
Rationale: The correct answer is B: Plan medication doses to occur before meals. This is because Myasthenia gravis can cause difficulty swallowing, leading to weight loss. Taking medication before meals can enhance the client's ability to eat by improving muscle strength for swallowing and chewing. Restricting fluids (A) may exacerbate swallowing difficulties. Increasing fat and carbohydrates (C) can lead to weight gain but may not address the swallowing issue. Eating three large meals (D) may be challenging for someone with swallowing difficulties.
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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.
A nurse is caring for a client who was injured by a blast of high-order explosives. Medics report secondary injuries from the explosion. The nurse anticipates what type of injuries?
- A. Blunt force trauma
- B. Hollow organ damage
- C. Post-trauma stress disorder
- D. Penetrating injuries
Correct Answer: D
Rationale: The correct answer is D: Penetrating injuries. High-order explosives cause secondary injuries like shrapnel or debris penetrating the body leading to penetrating injuries. Blunt force trauma (A) results from direct impact, not explosions. Hollow organ damage (B) is more likely with crush injuries. Post-trauma stress disorder (C) is a psychological response, not a physical injury. Therefore, the nurse should anticipate penetrating injuries as a result of the blast.
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.
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.
A nurse is determining if a homebound client is eligible for Meals-on-Wheels. Which of the following is the most important factor for the nurse to consider?
- A. The client's level of family support
- B. The client's financial resources
- C. The client's access to transportation
- D. The client's ability to prepare meals
Correct Answer: D
Rationale: The correct answer is D: The client's ability to prepare meals. This is crucial as Meals-on-Wheels provides food delivery for those unable to cook. By assessing the client's meal preparation ability, the nurse can determine if the service is necessary. Choice A may be helpful, but not as critical as the client's own ability. Choice B is important but not the most crucial for Meals-on-Wheels eligibility. Choice C is relevant, but if the client cannot prepare meals, transportation to get food is secondary.