Nokea
A student at an elementary school health fair reports having itchy circles on the lower legs. Which skin assessment finding should the nurse prioritize for immediate intervention?
- A. Patches of round lesions on both lower legs.
- B. Red ring-shaped lesions with normal skin in the center.
- C. Itchy, red, scaly patches with blisters that are draining.
- D. Several irritated circular bald, flaky scalp patches.
Correct Answer: C
Rationale: Itchy, red, scaly patches with blisters that are draining could be a sign of a serious skin infection such as cellulitis. This condition can spread quickly and become serious if not treated promptly, so it should be prioritized for immediate intervention.
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A graduate nursing student requests information, including laboratory findings and chest X-ray results, about all clients with symptoms of H1N1 who have been seen during the last month in a community health clinic. What action should the charge nurse take?
- A. Obtain written authorization from clients to release the information.
- B. Verify if permission has been obtained from the research committee.
- C. Ask the student to sign a standard waiver form.
- D. Provide the information for research purposes only.
Correct Answer: A
Rationale: A graduate nursing student requesting information, including laboratory findings and chest X-ray results, about all clients with symptoms of H1N1 who have been seen during the last month in a community health clinic is asking for sensitive patient information. This information is protected under privacy laws and regulations, such as the Health Insurance Portability and Accountability Act (HIPAA) in the United States. Therefore, the charge nurse should obtain written authorization from clients to release the information.
The nurse is caring for a patient with the sexually transmitted infection (STI) gonorrhea. The patient reports having multiple sexual partners. What response should the nurse provide?
- A. Emphasize that practicing safe sex eliminates the risk of STIs.
- B. Instruct the patient on the importance of informing sexual partners.
- C. Discuss that partners without similar symptoms may not be infected.
- D. Clarify that all STIs are transmitted through sexual intercourse.
Correct Answer: B
Rationale: Informing sexual partners about a gonorrhea diagnosis is crucial. Gonorrhea is a highly contagious infection that can be transmitted through sexual contact. If a person has been diagnosed with gonorrhea, their sexual partners may also be at risk and should be informed so they can seek testing and treatment if necessary.
A 42-year-old male client, who started experiencing mild flu-like symptoms 2 days ago, including an oral temperature of 101.2 °F (38.4 °C), came to the emergency department today due to increasing shortness of breath, cough, and chest pain. The client has no significant medical or surgical history. He occasionally drinks alcohol but denies smoking or drug use. He mentioned that he works in a government building and opened a package that was full of white powder. He may have inhaled some of the powder and coughed a few times but did not have any problems until a couple of days later. What actions should be taken?
- A. Apply oxygen via a nasal cannula.
- B. Place the client on a cardiorespiratory monitor.
- C. Infuse IV fluid boluses.
- D. Administer antiviral medication.
Correct Answer: B
Rationale: Given the client's symptoms and potential exposure to an unknown substance, it is crucial to monitor his vital signs and cardiorespiratory status. This will help healthcare providers detect any changes in the client's condition and respond appropriately.
A client comes to the clinic for an annual physical exam. When asked about their influenza vaccine status, the client responds, “I never get the vaccine because I don't get the flu.â€. Which aspect of the Health Belief Model is the client demonstrating?
- A. Perceived barriers.
- B. Perceived susceptibility.
- C. Perceived severity.
- D. Perceived benefits.
Correct Answer: A
Rationale: The client's decision not to get the flu vaccine because they don't get the flu demonstrates perceived barriers, one aspect of the Health Belief Model. The client may perceive that the potential discomfort or inconvenience of getting the vaccine outweighs the benefits.
After assessing the health care needs of an elementary school, the nurse determines that an increased prevalence of pediculosis capitis is a priority problem. The nurse develops a 2-month program with the goal to eradicate the condition in the school. The program includes educational pamphlets sent home to parents and regular assessment of children by the school nurse. What action should the nurse implement to evaluate the effectiveness of the program?
- A. Survey parents 3 weeks after pamphlets are sent home to assess their understanding of the condition.
- B. Evaluate the teacher's ability to identify pediculosis capitis 2 months after initiation of the program.
- C. Measure the prevalence of pediculosis capitis among the children after four months.
- D. Conduct an initial examination of each child in the school to obtain baseline data.
Correct Answer: C
Rationale: Measuring the prevalence of pediculosis capitis among the children after four months would directly assess the effectiveness of the program. A decrease in the prevalence of the condition would indicate that the program was effective.