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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 working with a care manager for a client who participates in a health maintenance organization. The nurse should identify that a health maintenance organization provides which of the following payment structures?
- A. The client is participating in a fee-for-service health care insurance program
- B. The provider is paid a fixed sum for the client on a monthly or yearly basis
- C. The client pays the insurer a percentage of the total costs for each service rendered by the provider
- D. The provider bills the client directly for a predetermined percentage of the cost of services
Correct Answer: B
Rationale: The correct answer is B. In a health maintenance organization (HMO), the provider is paid a fixed sum for the client on a monthly or yearly basis. This payment structure incentivizes providers to focus on preventive care and cost-effective treatments. This model aims to keep clients healthy and reduce unnecessary services.
A: Fee-for-service is not characteristic of an HMO.
C: This describes a cost-sharing model, not typical of an HMO.
D: Providers do not bill clients directly in an HMO.
A community health nurse is educating a parent about the importance of hepatitis B immunization. Which of the following explanations should the nurse give the parent about the disease?
- A. One dose of the immunization gives children lifelong protection from hepatitis B
- B. Hepatitis B spreads easily among children through casual contact
- C. Many people who acquire acute hepatitis B develop chronic hepatitis
- D. People who have had a hepatitis B infection still need the immunization
Correct Answer: C
Rationale: The correct answer is C: Many people who acquire acute hepatitis B develop chronic hepatitis. This explanation is important for the parent to understand the potential long-term consequences of hepatitis B infection. Acute hepatitis B can progress to chronic hepatitis in some cases, leading to liver damage and other complications. It highlights the seriousness of the disease and the importance of prevention through vaccination.
Choice A is incorrect because although hepatitis B vaccination provides long-lasting protection, it may not necessarily offer lifelong immunity. Choice B is incorrect as hepatitis B is primarily transmitted through exposure to infected blood or body fluids, not casual contact among children. Choice D is incorrect because prior infection does not confer complete immunity, so immunization is still recommended.
A community health nurse is working with a family that is struggling to adapt following the loss of a family member. Which of the following actions should the nurse take first?
- A. Refer the family to a grief support group.
- B. Determine the roles of individual family members.
- C. Encourage the family to assign specific tasks to individual family members.
- D. Assist the family to establish a daily routine.
Correct Answer: B
Rationale: The correct answer is B: Determine the roles of individual family members. This is the first step because understanding the roles within the family will help identify strengths and resources to support them through the grieving process. By determining roles, the nurse can assess each family member's needs and abilities, facilitating targeted interventions. Referral to a grief support group (A) may be beneficial later, but understanding family dynamics comes first. While assigning tasks (C) and establishing a routine (D) are important, they should come after identifying roles to ensure they are tailored to the family's specific needs.
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.
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.