Nokea
A nurse is providing teaching to a client who speaks a different language than the nurse, and an interpreter is present. Which of the following findings should the nurse document to show that the client understands the teaching?
- A. Client smiles at the nurse.
- B. Client asks questions to the interpreter.
- C. Client makes eye contact with the nurse frequently.
- D. Client points to printed resources when the nurse speaks.
Correct Answer: B
Rationale: The correct answer is B: Client asks questions to the interpreter. This indicates that the client is actively engaging with the information being provided, seeking clarification, and demonstrating an understanding of the teaching. Asking questions shows the client is processing the information and trying to make sense of it. Smiling at the nurse (A) may indicate politeness or agreement but does not necessarily reflect comprehension. Making eye contact (C) can show attentiveness but not necessarily understanding. Pointing to printed resources (D) may indicate a desire for more information but doesn't confirm comprehension.
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The partner of an older adult client who has Alzheimer's disease reports that he is not eating. The client's partner refuses to assist the client with feeding and insists the client feed himself without help. What is the priority action the nurse should take?
- A. Arrange for Meals on Wheels assistance
- B. Determine the client's ability to self-feed
- C. Direct the home health aide to assist with meals
- D. Refer the client's partner to an Alzheimer's support group
Correct Answer: B
Rationale: The correct answer is B: Determine the client's ability to self-feed. This is the priority action because it addresses the immediate concern of the client not eating due to the partner's refusal to assist. By assessing the client's ability to self-feed, the nurse can identify any barriers or challenges the client may be facing, such as physical limitations or cognitive impairments. This assessment will guide the nurse in developing an appropriate plan of care to ensure the client's nutritional needs are met.
The other choices are incorrect because they do not directly address the client's current situation.
A: Meals on Wheels assistance may be helpful but does not address the immediate need for the client to eat.
C: Directing the home health aide to assist assumes the client is willing to accept help, which may not be the case.
D: Referring the client's partner to an Alzheimer's support group is important for long-term support but does not address the immediate issue of the client not eating.
A 35-year-old client who has a diagnosis of tuberculosis informs the provider's office that she is unable to pay for the treatment. Which of the following actions by the nurse will facilitate obtaining appropriate treatment?
- A. Help the client apply for Medicare
- B. Explore options for alternative therapies
- C. Arrange for medication through local agencies
- D. Send the client to the nearest facility for further evaluation
Correct Answer: C
Rationale: The correct answer is C: Arrange for medication through local agencies. This option addresses the immediate need for treatment by connecting the client with resources that can provide medication for tuberculosis at little to no cost. This ensures that the client can access appropriate treatment despite financial constraints.
Option A (Help the client apply for Medicare) may not be feasible or timely, as the client may not qualify or the application process may take too long. Option B (Explore options for alternative therapies) is not appropriate for a serious infectious disease like tuberculosis that requires specific medical treatment. Option D (Send the client to the nearest facility for further evaluation) does not address the client's inability to pay for treatment and may delay necessary intervention.
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 nurse is working in a shelter following a disaster. Which of the following is the priority action for the nurse to take?
- A. Create diversionary activities for children
- B. Address the physical needs of clients
- C. Help clients gather needed supplies
- D. Explore feelings the clients are experiencing
Correct Answer: B
Rationale: The correct answer is B: Address the physical needs of clients. This is the priority action because in a disaster setting, ensuring the basic physical needs of clients such as food, water, shelter, and medical care takes precedence to ensure their survival and well-being. Without addressing these needs first, the clients' health and safety could be compromised. Creating diversionary activities for children (A), helping clients gather supplies (C), and exploring clients' feelings (D) are important but secondary to addressing immediate physical needs. It is crucial to prioritize basic survival needs before addressing emotional or social needs in a disaster situation.
Several nurses are developing a parish nurse group to help address the primary and secondary health care needs of the congregation. Which of the following services should the nurses plan to provide to the congregation?
- A. Organize an influenza immunization clinic with the American Red Cross
- B. Perform wound care in the home of members
- C. Provide end-of-life care for members who are terminal
- D. Facilitate discharge from the facility to the home
Correct Answer: A
Rationale: The correct answer is A: Organize an influenza immunization clinic with the American Red Cross. This service is important for promoting preventive health measures within the congregation. Influenza immunization helps reduce the spread of flu and protect vulnerable populations such as the elderly and young children. It aligns with the primary and secondary health care needs by focusing on prevention and early intervention. Providing wound care in members' homes (B) is more of a tertiary care service and may require specialized training and resources. End-of-life care (C) and discharge facilitation (D) are also important but may not directly address primary and secondary health care needs in this context.