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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A migrant farm worker who lives in a mobile home with several other workers visits the Migrant Health Care Center. The client reports Increasing episodes of dizziness, headaches, abdominal cramps, and difficulty breathing. Which nursing action has the highest priority?
- A. Gather information about the client's recent exposure to pesticides.
- B. Obtain a blood sample to assess for possible lead paint exposure.
- C. Ask about the length of his workday and frequency of rest breaks.
- D. Determine the number and age of persons living in the mobile home.
Correct Answer: A
Rationale: Symptoms like dizziness and breathing difficulty suggest pesticide poisoning, a common risk for farm workers, requiring immediate investigation to guide treatment.
One hundred families in a community refuse to have their children immunized because of religious beliefs. When one documented case of whooping cough occurs within this aggregate, which intervention should the nurse implement?
- A. Immunize all children under age 5 in the one hundred family aggregate.
- B. Immunize all members of the one hundred families.
- C. Quarantine the one hundred family aggregate.
- D. Quarantine all family members of the child with whooping cough.
Correct Answer: D
Rationale: Quarantining the affected child's family members prevents whooping cough spread, targeting those most likely exposed.
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.
The school nurse who is reviewing immunization records of students who will start kindergarten within the next month notes that most of the students have only received one dose of the measles, mumps, rubella (MMR) vaccine. Which intervention should the nurse implement?
- A. Contact kindergarten parents to remind them that the second dose of MMR is due at the start of the school year.
- B. Send notices home with the children on the first day of class advising that MMR vaccine series must be completed.
- C. Note in student records that the second dose of the MMR vaccine should be administered prior to entering first grade.
- D. Speak at the next parent-teacher association meeting to teach parents the benefits of immunizing their children.
Correct Answer: A
Rationale: Contacting parents before the school year ensures timely MMR second-dose administration, meeting school entry requirements.
A middle-aged client presents for an annual health visit at a community clinic. The client is 5 feet 10 inches (177.8 cm) tall, weighs 250 pounds (113.4 kg), and works as an accountant. The client has smoked at least one pack of cigarettes every day for the last 15 years. Which secondary prevention measure should the nurse recommend the client to follow?
- A. Smoking cessation.
- B. Compliance with antihypertensive and lipid lowering agents.
- C. Blood pressure and lipid screening.
- D. Increase physical activity and diet low in saturated fat.
Correct Answer: C
Rationale: Blood pressure and lipid screening are secondary prevention measures to detect cardiovascular issues early, critical for a smoker with obesity and high cardiovascular risk.