Nokea
During a home health visit a school age child who has muscular dystrophy confidesin 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 nurse's first priority is to ensure the safety and well-being of the child. Reporting to local authorities is crucial to protect the child from further harm and to initiate an investigation. Checking for injuries (B) is important but secondary to ensuring the child's safety. Referring the parent to a social service agency (C) or enrolling them in anger management classes (D) does not address the immediate safety concerns of the child. In this situation, immediate action through reporting to authorities is the most appropriate course of action.
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a community health nurse is providing teaching to a group of clients who have alcohol use disorder. which of the following findings should the nurse include in the teaching as a manifestation of alcohol withdrawal?
- A. bradycardia
- B. hypothermia
- C. increased appetite
- D. insomnia
Correct Answer: B
Rationale: The correct answer is B: hypothermia. Alcohol withdrawal can lead to a decrease in the body's ability to regulate temperature, resulting in hypothermia. This is due to alcohol's impact on the central nervous system's ability to regulate body temperature. Bradycardia (A) is not typically associated with alcohol withdrawal; increased appetite (C) is more commonly seen during the acute intoxication phase; insomnia (D) is a symptom of alcohol withdrawal, but it is not a manifestation related to temperature regulation.
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. motor vehicle safety
- B. sports injury prevention
- C. substance abuse prevention
- D. gun safety
Correct Answer: B
Rationale: The correct answer is B: sports injury prevention. Adolescents are more likely to die from sports-related injuries than any other cause listed. This is because sports activities carry inherent risks of serious injuries, such as head trauma or spinal cord injuries. By prioritizing sports injury prevention education, the school nurse can help reduce the likelihood of fatalities within this age group.
Choice A (motor vehicle safety) is also important, but statistics show that sports injuries are the leading cause of death for adolescents. Choice C (substance abuse prevention) and D (gun safety) are significant issues, but they are not the leading causes of death for this age group. Choices E, F, and G are not provided, so they are not relevant to this question.
The partner of an older adult client who has Alzheimer’s disease reports that he is not eating. The partner refuses to assist with feeding. Which of the following is the priority action the nurse should take?
- A. Arrange for Meals on Wheels assistance.
- B. Determine the client’s ability to self-feed.
- C. Direct the home health aide to assist with meals.
- D. Refer the client’s partner to an Alzheimer’s support group.
Correct Answer: B
Rationale: The correct answer is B: Determine the client's ability to self-feed. The priority action is to assess the client's capacity to feed themselves independently. This is crucial in identifying any issues or barriers the client may be facing in terms of feeding. By determining the client's ability to self-feed, the nurse can develop an appropriate plan of care tailored to the client's specific needs.
Choices A, C, and D are incorrect because they do not address the immediate concern of evaluating the client's ability to feed themselves. While arranging for Meals on Wheels or directing the home health aide to assist with meals may be helpful interventions, they do not address the root cause of the issue. Referring the client's partner to an Alzheimer's support group may be beneficial in the long term but does not address the immediate need to assess the client's ability to self-feed.
A nurse is providing teaching to a 50-year-old female client. Which of the following statements should the nurse include in the teaching?
- A. You should have a complete eye examination every 2 years until the age of 64.
- B. You should have your hearing screened every 5 years.
- C. You should have your stool tested for blood every other year until the age of 74.
- D. You should have your fasting blood glucose level checked every 6 years.
Correct Answer: C
Rationale: The correct answer is C: You should have your stool tested for blood every other year until the age of 74. This is important for early detection of colorectal cancer, which is recommended starting at age 50. Stool testing for blood helps identify any signs of bleeding in the digestive tract, a potential indicator of colorectal cancer. The other choices are incorrect because eye examinations should be done annually after age 65, hearing screening should be done every 3-5 years, fasting blood glucose should be checked more frequently for diabetes screening, and stool testing for blood should be continued beyond age 74 due to the ongoing risk of colorectal cancer.
nurse expect
- A. oliguria
- B. diplopia
- C. hypoglycemia
- D. dizziness
Correct Answer: B
Rationale: The correct answer is B: diplopia. Nurses expect diplopia in a patient as it can indicate a serious neurological issue or cranial nerve dysfunction. Oliguria (A) refers to decreased urine output, not typically associated with nursing expectations. Hypoglycemia (C) is a metabolic condition, not typically anticipated by nurses. Dizziness (D) can have various causes and is not specific enough to be expected by a nurse.