Nokea
A school nurse is assessing a child who has been stung by a bee. The child's hand is swelling, and the nurse notes that the child is allergic to insect stings. Which of the following findings should the nurse expect if the child develops anaphylaxis? (SATA)
- A. Bradycardia
- B. Nausea
- C. Hypertension
- D. Urticaria
- E. Stridor
Correct Answer: B, D, E
Rationale: Correct Answer: B, D, E
Rationale:
1. Nausea: Anaphylaxis can cause gastrointestinal symptoms like nausea due to the release of inflammatory mediators.
2. Urticaria: Anaphylaxis commonly presents with hives (urticaria) as a manifestation of allergic reaction.
3. Stridor: Anaphylaxis can lead to upper airway swelling, causing stridor due to compromised breathing.
Summary of Incorrect Choices:
A. Bradycardia: Anaphylaxis typically causes tachycardia due to the body's response to the allergen.
C. Hypertension: Anaphylaxis usually results in hypotension due to vasodilation and increased vascular permeability.
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A nurse is caring for a client who is having difficulty performing activities of daily living. The nurse is functioning in which of the following roles when arranging for an occupational therapist to visit the client?
- A. Administrator
- B. Nurse consultant
- C. Case manager
- D. Clinician
Correct Answer: C
Rationale: The correct answer is C: Case manager. In this scenario, the nurse is functioning as a case manager by coordinating and arranging for the occupational therapist to visit the client. A case manager is responsible for coordinating care services and resources for clients to meet their healthcare needs. A nurse consultant (B) provides expert advice and guidance but does not typically coordinate services like a case manager. An administrator (A) is in charge of managing the overall operations of a healthcare facility. A clinician (D) directly provides healthcare services to clients. In this situation, the nurse is not assuming these roles but rather acting as a case manager to ensure the client receives the necessary occupational therapy services.
A nurse in a mobile health clinic is caring for a client who requires a tetanus immunization and is accompanied by his daughter. The client does not speak the same language as the nurse. Which of the following actions should the nurse take?
- A. Have the client's daughter communicate information about the procedure
- B. Arrange for a member of the client's community to interpret the teaching
- C. Identify the client's spoken dialect prior to contacting an interpreter
- D. Use professional terminology when providing education prior to the procedure
Correct Answer: C
Rationale: The correct answer is C: Identify the client's spoken dialect prior to contacting an interpreter. This is the most appropriate action because it ensures effective communication by matching the client with an interpreter who speaks the same dialect. This step shows cultural sensitivity and respects the client's language preference, promoting trust and understanding.
Other choices are incorrect:
A: Having the client's daughter communicate may not guarantee accurate information exchange due to potential language barriers.
B: Arranging for a community member to interpret may not ensure confidentiality or accuracy in communication.
D: Using professional terminology without ensuring understanding may lead to confusion and hinder effective communication.
A home health nurse is scheduled for a first-time visit to a client. Which of the following should the nurse perform first?
- A. Blood pressure screening
- B. Mental status examination
- C. Review of the neighborhood
- D. Family history
Correct Answer: C
Rationale: The correct answer is C: Review of the neighborhood. This should be performed first to assess the safety and environment of the client's home, ensuring the nurse's safety and the ability to provide care effectively. It helps identify potential hazards or resources in the community. Blood pressure screening (A) can wait until after ensuring a safe environment. Mental status examination (B) is important but can be conducted after assessing the neighborhood. Family history (D) is not a priority for the first visit.
A nurse is caring for a client who is homeless. Which of the following actions should the nurse take first?
- A. Determine the client's understanding of her living situation
- B. Assist the client to develop goals for obtaining shelter
- C. Discuss the risks of being homeless with the client
- D. Develop client teaching using a variety of strategies
Correct Answer: A
Rationale: The correct answer is A: Determine the client's understanding of her living situation. This is the first step because it allows the nurse to assess the client's current situation and needs. Understanding the client's perspective is crucial for providing effective care and support. Assisting the client in developing goals (B) or discussing risks (C) should come after understanding the client's current situation. Developing client teaching (D) is important but should be based on the client's understanding and needs, which is why it comes after assessing their understanding.
A school nurse is implementing health screening. Which of the following assessment findings should the nurse recognize as the highest priority?
- A. A child who has a BMI of 18
- B. An adolescent who has scoliosis
- C. An adolescent who has psoriasis
- D. A child who has nits
Correct Answer: B
Rationale: The correct answer is B: An adolescent who has scoliosis. Scoliosis is a spinal deformity that can progress and cause serious health issues if left untreated. The school nurse should prioritize this assessment finding to ensure early detection and appropriate interventions to prevent further complications. A: A child with a BMI of 18 may indicate underweight but is not as urgent as scoliosis. C: Psoriasis is a skin condition that may require management but is not immediately life-threatening. D: Nits (lice eggs) are a common issue but do not pose a significant health risk compared to scoliosis.