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A school nurse is developing a health risk screening protocol for use at an elementary school. Which information is most important for the nurse to include in this protocol?
- A. Long bone density testing.
- B. Annual flu vaccination status.
- C. Weight and height measurement.
- D. Serum total cholesterol level.
Correct Answer: C
Rationale: Weight and height measurements are essential for assessing growth, detecting malnutrition or obesity, and monitoring overall health in elementary students.
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Several clients who have recently come to the local health clinic in a rural county are diagnosed with tuberculosis (TB). After reporting the occurrence to the health department, which community focused action should the nurse implement first?
- A. Collaborate with local schools in screening children.
- B. Develop a community educational program.
- C. Provide referrals for home health care follow up.
- D. Perform a community health assessment.
Correct Answer: D
Rationale: A community health assessment is the first step to understand the extent of the TB outbreak, identify high-risk groups, and tailor interventions like screening or education effectively.
A prescription for discharge is written for an elderly client who has asked to be discharged to home. The client lives alone and is able to walk 10 to 15 feet (3 to 4.5 meters) with assistance. Which action should the nurse implement first?
- A. Review the home medication schedule with the client and family.
- B. Provide the client with information about medical alert devices.
- C. Arrange for a bedside commode to be delivered to the home.
- D. Meet with the case manager to plan a home safety evaluation.
Correct Answer: D
Rationale: A home safety evaluation is critical to identify hazards and ensure the client's limited mobility is accommodated, preventing falls and ensuring safety.
The nurse is documenting the medical history of a young adult client who was recently diagnosed with type 1 diabetes mellitus. The client smokes 2 packs of cigarettes daily and the client's father died of a heart attack at the age of 45. Which annual screening is most important for the nurse include?
- A. Renal insufficiency.
- B. Peripheral neuropathy.
- C. Hyperlipidemia.
- D. Retinopathy.
Correct Answer: C
Rationale: Given the client's smoking habit and family history of early heart attack, screening for hyperlipidemia is critical to address cardiovascular risk, which is heightened by these factors and diabetes.
The elementary school nurse has identified a problem requiring a secondary intervention. Which intervention should the nurse implement?
- A. Instruct on technique of 'stop, drop & roll' at assembly.
- B. Involve the parent teacher association (PTA) in a fund raising event for the new gym.
- C. Invite 1st grade parents to a 'Meet the Teachers' event.
- D. Send letters to parents regarding a recent lice infestation.
Correct Answer: D
Rationale: Sending letters about a lice infestation is a secondary prevention intervention, addressing an identified problem to control its spread.
A school nurse identifies 15 new students with positive tuberculin tests among the 500 at-risk students tested. Which is the rate per 1,000 with new positive tests?
- A. 3/1,000.
- B. 30/1,000.
- C. 1.7/1,000.
- D. 15/1,000.
Correct Answer: B
Rationale: The rate is calculated as (15/500) * 1,000 = 30/1,000, accurately reflecting the proportion of students with positive tests per 1,000.