Nokea
A toddler is brought by a parent to the health department for scheduled immunizations. The toddler clings to the caregiver and cowers when approached. Which assessment warrants immediate intervention by the nurse?
- A. Small bruises on the lower extremities.
- B. A one-inch laceration across center of forehead.
- C. Refusal to answer simple questions.
- D. Several dime-sized circular burns on the back.
Correct Answer: D
Rationale: Circular burns are suggestive of abuse, requiring immediate intervention to ensure the child's safety and further investigation.
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The school nurse is assessing a group of middle school students for signs of scoliosis and discovers a student with a noticeable unequal symmetry of the upper and lower back. Which intervention is most important for the nurse to implement?
- A. Make a referral to have the scoliosis further evaluated.
- B. Measure the degree of the thoracic and lumbar curvature.
- C. Ask about the student's ability to participate in sports.
- D. Review students health record for a recent growth spurt.
Correct Answer: A
Rationale: Referring for further evaluation by a specialist ensures accurate diagnosis and timely management of potential scoliosis, addressing the observed asymmetry.
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 community health nurse believes that immunization rates in a lower-socioeconomic section of the city are probably below the target set by the state health department. Which action should the nurse take first to intervene with this health problem?
- A. Review current epidemiological population data that might document a low immunization rate.
- B. Call a meeting of citizens to inform them of the importance of having their children immunized.
- C. Join a political action group that focuses attention on the issue in the local news media.
- D. Partner with a local children's hospital in setting up free 'shot' clinics in the neighborhood.
Correct Answer: A
Rationale: Reviewing epidemiological data confirms the extent of low immunization rates, providing a foundation for targeted interventions.
Which annual screening should the nurse include when planning an eye health program at a preschool?
- A. Glaucoma.
- B. Red light reflex.
- C. Visual acuity.
- D. Conjunctivitis.
Correct Answer: C
Rationale: Visual acuity screening is essential for preschoolers to detect vision issues like amblyopia or refractive errors that could impact development and learning, making it the priority for annual eye health programs.
The nurse is teaching adults in the community about suicide awareness. Which information should the nurse include in the teaching?
- A. Suicide discussion is dangerous with people with depression.
- B. The majority of suicides occur in lower socioeconomic groups.
- C. Social support systems ensure suicide prevention.
- D. Severe life stresses at any age is a risk factor for suicide.
Correct Answer: D
Rationale: Severe life stresses are a well-established risk factor for suicide across all ages, critical for awareness and prevention efforts.