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During a home health visit, the nurse observes that an elderly client with type 2 diabetes mellitus is wearing loose cloth slippers. The client reports discomfort when wearing other shoes due to long toenails. Upon inspection, the nurse finds long, thick nails that curl under some of the client's toes. What should the nurse do in this situation?
- A. Demonstrate proper foot care to the client and family.
- B. Gradually trim the client's toenails over several visits.
- C. Arrange for a home health aide to assist the client with hygiene weekly.
- D. Schedule an appointment for the client with a podiatrist.
Correct Answer: D
Rationale: Scheduling an appointment for the client with a podiatrist is the best option. A podiatrist is a healthcare professional who specializes in foot care. They can safely trim the client's long, thick toenails and assess for any other foot-related issues.
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The number of students seeking information about teenage pregnancy has risen by 259%. Two years ago, a nurse evaluated the health needs of high school students and identified student pregnancy as a significant issue. As a result, the nurse created a pregnancy prevention program for the entire school district. Which outcome is the strongest evidence of the program's success?
- A. 80% of the students participate in a voluntary sex education seminar.
- B. Students report an average delay of 2 years for their first sexual encounter.
- C. 75% of the parents express support for a pregnancy prevention program in the schools.
- D. The school district reports a decrease in the number of teenage pregnancies.
Correct Answer: D
Rationale: A decrease in the number of teenage pregnancies in the school district is the strongest evidence of the program's success. This outcome directly aligns with the goal of a pregnancy prevention program, which is to reduce the number of teenage pregnancies.
During a routine office visit, a nurse is obtaining an older adult client's vital signs and notices the caregiver is very quiet and withdrawn. When asked, the caregiver acknowledges feeling exhausted from caring for the client 24 hours a day. What is the best information for the nurse to provide?
- A. Suggest that social services be contacted to find a respite care facility for the client.
- B. Tell the caregiver to consider hiring a private nurse to provide some time away.
- C. Advise a case management evaluation of the client's home environment.
- D. Recommend that the client's family return to the area to help provide assistance.
Correct Answer: A
Rationale: Respite care is a service that provides temporary relief to primary caregivers, allowing them time to rest and take care of their own needs. It can be provided in the client's home, a healthcare facility, or an adult day care center. This service is especially beneficial for caregivers who are feeling exhausted, as it offers them a break while ensuring that their loved ones continue to receive care.
A home health nurse is examining the lab results of several patients with a history of heart failure (HF). Which patient's finding should the nurse immediately report to the healthcare provider?
- A. Potassium level of 3.7 mEq/L (3.7 mmol/L).
- B. B-type natriuretic peptide (BNP) level of 550 pg/mL (550 ng/L).
- C. Total cholesterol level of 190 mg/dL (4.92 mmol/L).
- D. Glycosylated hemoglobin (A1C) level of 7%.
Correct Answer: B
Rationale: B-type natriuretic peptide (BNP) levels are used to diagnose and monitor heart failure. A BNP level of 550 pg/mL (550 ng/L) is significantly higher than the normal range, which is less than 100 pg/mL. High BNP levels indicate that the heart is working harder than normal, which is a common occurrence in heart failure. Therefore, this result should be reported immediately to the healthcare provider.
A client was admitted to the community palliative care unit ten years after being diagnosed with multiple sclerosis (MS). Which intervention should the nurse prioritize in the client's care plan?
- A. Allow the family to visit whenever they wish.
- B. Administer medication as needed for pain and anxiety.
- C. Maintain a quiet environment with low lighting.
- D. Allow the client to participate in the care provided.
Correct Answer: B
Rationale: Administering medication as needed for pain and anxiety should be prioritized in the care plan for a client with MS in a palliative care unit. MS can cause varying degrees of pain and anxiety, and managing these symptoms can significantly improve the client's quality of life during the advanced stages of the disease.
A community health nurse who works in a Gulf Coast town that caters to tourists is conducting a disaster management class for residents and business owners. What is the most important content for the nurse to include in this class?
- A. Methods used to treat water to ensure it is safe to drink.
- B. Available evacuation routes from the town.
- C. Hurricane preparedness for families and businesses.
- D. Actions to be taken during a tornado.
Correct Answer: C
Rationale: Given the geographical location of the Gulf Coast town, hurricane preparedness for families and businesses is the most important content to include in the class. Hurricanes are a common natural disaster in this area, and being prepared can help reduce the impact of such events.