Nokea
An adolescent tells the school nurse that she is pregnant. Her last menstrual period was 4 months ago, and she has not yet received any medical care. She smokes but denies any other substance use. Which interventions should the nurse implement? (Select all that apply.)
- A. Encourage smoking cessation.
- B. Arrange for childcare.
- C. Offer nutritional instruction.
- D. Refer for prenatal care.
- E. Teach breastfeeding methods.
- F. Notify her parents.
Correct Answer: A,C,D
Rationale: Smoking cessation, nutritional instruction, and prenatal care referral are critical to improve maternal and fetal health outcomes. Childcare and breastfeeding education are less immediate, and notifying parents requires careful consideration of confidentiality.
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The community health center has noticed a dramatic increase in influenza cases over prior years. The facility nurses have been charged with reviewing outcome data to determine if there is a trend in vaccination rates, and if a trend is noted, reasons for decline. An action plan will be developed to increase rates, if needed. The facility nursing team develops a plan to survey the community and facility records. Select all applicable action(s) that will facilitate gathering data for analysis.
- A. Client survey both in clinic and in the home
- B. Ask a set number of clients if they have had the flu
- C. Determine change in immunization rates from prior year to current year
- D. Generate influenza immunization and case reports from the electronic record for prior year and current year
- E. Develop an action plan to increase immunization rates
- F. Delineate geographic distribution of area to survey and review for patterns
Correct Answer: A,C,D,F
Rationale: Surveys (A), immunization rate changes (C), electronic record reports (D), and geographic distribution analysis (F) provide comprehensive data to identify vaccination trends and patterns.
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.
A nurse is interested in studying the incidence of infant death in a particular city and wants to compare that city's rate to the state's rate. Which state resource should the nurse select to gather this information?
- A. Census data.
- B. Bureau of Vital Statistics.
- C. Disease registry.
- D. Department of Health.
Correct Answer: B
Rationale: The Bureau of Vital Statistics provides detailed data on vital events like deaths, making it the best resource for accurate infant mortality rates for city and state comparisons.
On a day when the temperature is expected to drop to below freezing during the night, the nurse is asked to determine which homeless adults are most in need of the limited spaces that are available in a shelter. It is most important for which person to be admitted for the night?
- A. A young person with diabetes mellitus.
- B. A middle-aged person who has hypertension.
- C. An older person who is malnourished.
- D. An adult who was hit by a car 3 weeks ago.
Correct Answer: C
Rationale: A malnourished older person is most vulnerable to hypothermia due to impaired thermoregulation, making shelter critical to prevent cold-related illnesses.
While assessing a child at the community health clinic, the nurse notes that the toddler has multiple bruises on his legs and buttocks. After reporting suspected child abuse to the supervisor, which action should the nurse take next?
- A. Obtain a restraining order against the father.
- B. Encourage the mother to file a police report.
- C. Ask the child if his father ever spanks him.
- D. Refer the family to protective service agencies.
Correct Answer: D
Rationale: Referring to protective service agencies ensures a specialized investigation and intervention, prioritizing the child's safety and well-being.