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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.
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A home health nurse is visiting a client who had a stroke 2 months ago. Which of the following findings should the nurse report to the interprofessional care team?
- A. The client dresses her affected side first.
- B. The client bears weight on their arms when using crutches.
- C. The client coughs when swallowing her medications.
- D. The client's caregiver fills a pill organizer weekly.
Correct Answer: C
Rationale: The correct answer is C: The client coughs when swallowing her medications. This finding should be reported because coughing when swallowing can indicate dysphagia, a common complication after a stroke that can lead to aspiration pneumonia. Aspiration pneumonia is a serious condition that requires immediate attention to prevent respiratory complications. Reporting this finding to the interprofessional care team allows for prompt assessment and intervention to prevent further complications.
Choices A, B, and D are not as urgent to report to the interprofessional care team. A client dressing their affected side first, bearing weight on arms with crutches, or a caregiver filling a pill organizer weekly do not pose immediate risks to the client's health and do not require immediate intervention from the care team. These findings are important for monitoring the client's progress and adjusting care plans but do not have the same level of urgency as coughing when swallowing medications.
A nurse is planning a priority intervention to reduce obesity in the community. Which of the following actions should the nurse take?
- A. Encourage enrollment and attendance at weight reduction programs
- B. Educate children at a daycare center about nutrition and exercise
- C. Distribute health risk appraisal questionnaires at community functions
- D. Measure the BMI of older adults at a community senior center
Correct Answer: B
Rationale: The correct answer is B: Educate children at a daycare center about nutrition and exercise. This is the priority intervention because educating children about nutrition and exercise can help prevent obesity in the long term. By teaching healthy habits early on, the nurse can make a significant impact on reducing obesity rates in the community. Encouraging enrollment in weight reduction programs (A) may help individuals who are already obese but does not address prevention. Distributing health risk appraisal questionnaires (C) and measuring BMI of older adults (D) are important but not the priority for reducing obesity in the community.
A community health nurse is providing teaching to a group of clients who have alcohol use disorder. Which of the following findings should the nurse include in the teaching as a manifestation of alcohol withdrawal?
- A. Bradycardia
- B. Hypothermia
- C. Increased appetite
- D. Insomnia
Correct Answer: D
Rationale: The correct answer is D: Insomnia. Alcohol withdrawal commonly presents with symptoms such as difficulty sleeping, restlessness, and anxiety due to the disruption of the central nervous system. Insomnia is a hallmark manifestation of alcohol withdrawal syndrome. Bradycardia (A) is not typically associated with alcohol withdrawal; instead, tachycardia is more common. Hypothermia (B) is rare in alcohol withdrawal, as alcohol tends to cause vasodilation and can lead to increased body temperature. Increased appetite (C) is not a typical symptom of alcohol withdrawal; in fact, decreased appetite or nausea is more common. Therefore, the correct choice is D based on the typical manifestations of alcohol withdrawal.
A nurse of a community clinic is preparing an educational guide about cultural variances in expression of pain. Which of the following information should the nurse include?
- A. Middle Eastern cultural practices include hiding pain from close family members
- B. Native American cultural practices include being outspoken about pain
- C. Puerto Rican cultural practices include the view that outspoken expressions of pain are shameful
- D. Chinese cultural practices include enduring pain to prevent family dishonor
Correct Answer: D
Rationale: The correct answer is D: Chinese cultural practices include enduring pain to prevent family dishonor. In Chinese culture, there is a strong emphasis on family honor and saving face. Expressing pain openly may be viewed as a sign of weakness and may bring shame to the family. Therefore, individuals may choose to endure pain silently to avoid dishonoring their family.
Explanation for other choices:
A: Middle Eastern cultural practices include hiding pain from close family members - This is not necessarily a common practice in Middle Eastern cultures and may not accurately represent the diverse ways pain is expressed.
B: Native American cultural practices include being outspoken about pain - While some Native American cultures may value openness about pain, it is not a universal practice among all tribes and communities.
C: Puerto Rican cultural practices include the view that outspoken expressions of pain are shameful - While there may be individuals within Puerto Rican culture who hold this belief, it is not a widely recognized cultural practice.
An occupational health nurse is discussing health promotion with a client who has a history of obesity. Which of the following comments indicates the client is using rationalization as a coping mechanism?
- A. I have lots of health problems from being obese
- B. I am obese, it's in my genes
- C. I have difficulty resisting the items in vending machines
- D. I know you don't like me because I am obese
Correct Answer: B
Rationale: The correct answer is B because the client is using rationalization by attributing their obesity to genetics rather than taking personal responsibility. This deflects accountability and provides a justification for their weight issue. Choice A acknowledges the health problems related to obesity. Choice C acknowledges a specific struggle with resisting temptations. Choice D reflects projection, attributing dislike to the nurse. Other choices are incomplete.