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During a home health visit, a school-age child who has muscular dystrophy confides in the nurse that he was struck by his parents. Which of the following actions should the nurse take first?
- A. Report the incident to local authorities.
- B. Check the child for injuries.
- C. Refer the parent to a social service agency.
- D. Enroll the parent in anger management classes.
Correct Answer: A
Rationale: The correct answer is A: Report the incident to local authorities. The first priority in this situation is to ensure the safety and well-being of the child. By reporting the incident to local authorities, the nurse can initiate a formal investigation to protect the child from further harm. Checking for injuries (B) is important but secondary to ensuring the child's safety. Referring the parent to a social service agency (C) may be appropriate but not the first step in cases of suspected abuse. Enrolling the parent in anger management classes (D) is not the immediate priority when a child is at risk of harm.
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An occupational health nurse is discussing health promotion with a client who has a history of obesity. Which of the following comments indicates the client is using rationalization as a coping mechanism?
- A. I have lots of health problems from being obese
- B. I am obese, it's in my genes
- C. I have difficulty resisting the items in vending machines
- D. I know you don't like me because I am obese
Correct Answer: B
Rationale: The correct answer is B because the client is using rationalization by attributing their obesity to genetics rather than taking personal responsibility. This deflects accountability and provides a justification for their weight issue. Choice A acknowledges the health problems related to obesity. Choice C acknowledges a specific struggle with resisting temptations. Choice D reflects projection, attributing dislike to the nurse. Other choices are incomplete.
A school nurse is planning safety education for a group of adolescents. The nurse should give priority to which of the following topics as the leading cause of death for this age group?
- A. Sports injury prevention
- B. Motor vehicle safety
- C. Substance abuse prevention
- D. Gun safety
Correct Answer: B
Rationale: The correct answer is B: Motor vehicle safety. Adolescents are at a higher risk of motor vehicle accidents, making it the leading cause of death in this age group. This is due to factors like inexperience, risk-taking behaviors, and distractions while driving. Sports injury prevention (A) is important but not the leading cause of death. Substance abuse prevention (C) is significant but not the primary cause of death. Gun safety (D) is also crucial but not as prevalent as motor vehicle accidents.
A nurse is working to reduce individual and family violence in the local community. Which of the following actions by the nurse demonstrates a primary prevention strategy to achieve this goal?
- A. Conducting counseling for at-risk parents
- B. Assessing a family for marital discord
- C. Teaching parenting techniques to new parents
- D. Providing treatment for a young adult who has a substance use disorder
Correct Answer: C
Rationale: The correct answer is C: Teaching parenting techniques to new parents. This is a primary prevention strategy because it focuses on educating parents before any violence occurs. By providing new parents with effective parenting techniques, the nurse is helping to prevent the occurrence of violence in the first place. This intervention addresses the root cause and promotes a positive family environment.
Choices A, B, and D are not primary prevention strategies. Conducting counseling for at-risk parents (A) is a secondary prevention strategy as it aims to intervene with individuals already at risk. Assessing a family for marital discord (B) is also a secondary prevention strategy as it involves identifying existing issues. Providing treatment for a young adult with a substance use disorder (D) is a tertiary prevention strategy, focusing on treating the individual after the issue has already developed.
A client states, 'My life has no meaning right now.' What is the nurse's best response?
- A. Have you been thinking about harming yourself?
- B. How long have you been feeling this way?
- C. Tell me what is going on with you right now.
- D. Do you really think your life has no purpose?
Correct Answer: A
Rationale: The correct answer is A. By asking the client if they have been thinking about harming themselves, the nurse is directly addressing the potential risk of suicide, which is crucial when a client expresses feelings of hopelessness. This question helps assess the client's safety and determine the need for immediate intervention. Choices B, C, and D are not as direct in addressing the potential risk of self-harm and may not provide the necessary urgency in ensuring the client's safety. Asking about self-harm is critical in assessing the severity of the client's distress and ensuring appropriate interventions are implemented promptly.
A nurse working in an infectious disease clinic is caring for a client who has a new diagnosis of Lyme disease. Which of the following agencies is responsible for voluntarily reporting cases of this disease to the Centers for Disease Control and Prevention?
- A. Office of the Surgeon General
- B. State Department of Health
- C. Hospital infection control department
- D. Local Red Cross chapter
Correct Answer: B
Rationale: The correct answer is B: State Department of Health. The State Department of Health is responsible for voluntarily reporting cases of Lyme disease to the Centers for Disease Control and Prevention (CDC) because they are tasked with monitoring and controlling the spread of infectious diseases within their jurisdiction. They have the mandate to collect and report data on disease outbreaks to the CDC, enabling national surveillance and response efforts. The other choices are incorrect because the Office of the Surgeon General does not have direct jurisdiction over disease reporting, the hospital infection control department focuses on internal infection control measures, and the Local Red Cross chapter is primarily involved in disaster relief and blood services, not disease surveillance.