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An older adult client visits the community health clinic, reporting the onset of pain, redness, and swelling in the right eye. What is the most important for the clinic nurse to ask the client?
- A. Do you have any discharge from the eye?
- B. Are all of your immunizations up-to-date?
- C. Have you started any new medications recently?
- D. How frequently do you wash your hands?
Correct Answer: A
Rationale: If an older adult client reports pain, redness, and swelling in the eye, asking about discharge from the eye is crucial. These symptoms could indicate a number of conditions, including conjunctivitis or uveitis. Discharge, especially if it is pus-like or sticky, could suggest an infection.
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An older adult client has lost 5 lbs (2.3 kg) since their last check-up a month ago. The client maintains good hygiene, still drives, and lives alone. To which organization should the parish nurse refer this client?
- A. The Social Security Administration office.
- B. The Senior Citizen Center.
- C. The Women, Infants, and Children office.
- D. The Adult Day Care Center.
Correct Answer: B
Rationale: The Senior Citizen Center offers a variety of services to older adults, including meal programs, health and wellness programs, and opportunities for social interaction. This could help address the client's weight loss and potential social isolation.
During a two-week postoperative follow-up home visit, a client who had gastric bypass surgery exhibits abdominal tenderness, shoulder pain, and feelings of malaise. The client's vital signs are an oral temperature of 101.80F (38.8° C), a blood pressure of 100/50 mm Hg, a heart rate of 104 beats/minute, and a respiratory rate of 18 breaths/minute. What is the appropriate action for the nurse to take?
- A. Recheck the client's vital signs in 30 minutes.
- B. Have the client transported via ambulance to the hospital.
- C. Determine the client's current oxygen saturation rate.
- D. Instruct the client to drive to the hospital for admission.
Correct Answer: B
Rationale: Having the client transported via ambulance to the hospital is the most appropriate action. The client's symptoms suggest possible complications that require immediate medical attention. Abdominal tenderness and shoulder pain could indicate a serious condition such as a perforation or infection.
The public health nurse is assessing resources in a rural community. Which healthcare resource is of utmost importance to the community?
- A. Annual health fair.
- B. Family planning center.
- C. Access to trauma care.
- D. Plan for weather-related disasters.
Correct Answer: C
Rationale: Access to trauma care is crucial in rural areas where distances to hospitals can be great. Injuries and acute illnesses require immediate attention, and having access to trauma care can significantly improve outcomes.
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.
During a home visit, the nurse observes an elderly patient trying to walk to the bathroom. The patient appears unstable and clings to furniture while refusing any help. What action should the nurse take?
- A. Suggest that the patient get a walker.
- B. Encourage the patient to acquire a medical alert device.
- C. Ensure the patient's privacy while in the bathroom.
- D. Identify potential safety hazards in the home.
Correct Answer: D
Rationale: Identifying potential safety hazards in the home is the most immediate and effective action the nurse can take. By doing this, the nurse can work with the patient and their family to make necessary changes to improve safety and prevent falls.