Nokea
During a home visit, the nurse observes an elderly client with disabilities slip and fall. What action should the nurse take first?
- A. provide the client with 4 ounces of orange juice
- B. call 911 to summon emergency assistance
- C. check the client for lacerations or fractures
- D. assess the client's blood sugar level
Correct Answer: C
Rationale: The correct action for the nurse to take first after an elderly client with disabilities slips and falls is to check the client for lacerations or fractures. This is crucial to assess the extent of injuries and provide appropriate medical attention promptly. Option A, providing orange juice, is not a priority in this situation and does not address the potential injuries. While calling 911 (Option B) may be necessary, assessing for immediate injuries takes precedence. Assessing the client's blood sugar level (Option D) is not the immediate priority after a fall unless there is a specific indication or suspicion of hypoglycemia.
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A public health nurse is working with a community to improve access to healthcare services. Which intervention is most likely to be effective?
- A. Setting up mobile clinics in underserved areas
- B. Distributing flyers with information about local clinics
- C. Offering transportation vouchers for medical appointments
- D. Partnering with local businesses to provide healthcare discounts
Correct Answer: A
Rationale: Setting up mobile clinics in underserved areas is the most effective intervention to improve access to healthcare services. Mobile clinics directly bring healthcare services to the community, making it convenient for residents to access care without having to travel long distances. Distributing flyers may increase awareness but may not address the barriers to access. Offering transportation vouchers helps with one aspect of access but does not directly provide healthcare services. Partnering with local businesses for discounts may not address the primary issue of physical access to healthcare services in underserved areas.
The client with newly diagnosed type 1 diabetes mellitus is being taught about insulin administration by the nurse. Which statement indicates that the client needs further teaching?
- A. I will inject my insulin into my abdomen for the fastest absorption.
- B. I will rotate injection sites to prevent lipodystrophy.
- C. I will store my insulin in the refrigerator at all times.
- D. I will rotate injection sites to prevent lipodystrophy.
Correct Answer: C
Rationale: The correct answer is C. Insulin should not be stored in the refrigerator at all times; it should be kept at room temperature when in use to avoid irritation at the injection site. Storing insulin in the refrigerator can cause it to thicken and may lead to discomfort upon injection. Choices A and D are correct statements as injecting insulin into the abdomen for faster absorption and rotating injection sites to prevent lipodystrophy are appropriate insulin administration techniques. Therefore, the client does not need further teaching on these aspects.
The nurse is documenting the medical history of a young adult who was recently diagnosed with type 1 diabetes mellitus. The client smokes 2 packs of cigarettes a day, and his father died of a heart attack at the age of 45. Which annual screening is most important for the nurse to include?
- A. peripheral neuropathy
- B. renal insufficiency
- C. retinopathy
- D. hyperlipidemia
Correct Answer: D
Rationale: The most important annual screening for the nurse to include is hyperlipidemia. Given the client's smoking history, family history of premature heart disease, and the increased risk of cardiovascular complications associated with diabetes, screening for hyperlipidemia is crucial. This screening is essential in assessing the client's risk of developing cardiovascular disease, which is a significant concern in this case. Peripheral neuropathy (choice A) is a common long-term complication of diabetes but may not be the most immediate concern in this scenario. Renal insufficiency (choice B) is also a complication of diabetes, but given the client's high cardiovascular risk, hyperlipidemia screening takes priority. Retinopathy (choice C) is an important complication of diabetes affecting the eyes, but in this case, focusing on cardiovascular risk assessment through hyperlipidemia screening is more critical.
A male client who had abdominal surgery has a nasogastric tube for suction, oxygen via nasal cannula, and complains of dry mouth. Which action should the nurse implement?
- A. Apply a petroleum-based lubricant to the lips.
- B. Give sips of water.
- C. Provide ice chips.
- D. Apply a water-soluble lubricant to the lips, oral mucosa, and nares.
Correct Answer: D
Rationale: In this scenario, the correct action is to apply a water-soluble lubricant to the lips, oral mucosa, and nares. This helps in keeping the mucous membranes moist, which is essential for a client with a dry mouth due to the nasogastric tube and oxygen therapy. Choice A, applying a petroleum-based lubricant to the lips, is not suitable as it may not be safe for internal use. Choice B, giving sips of water, is contraindicated as the client has a nasogastric tube in place for suction. Choice C, providing ice chips, is also not recommended as the client needs proper lubrication to address dryness, not cold stimulation.
The healthcare provider is planning a health education session for new parents on infant care. Which topic should be prioritized?
- A. signs of infant dehydration
- B. proper diaper changing techniques
- C. immunization schedule
- D. breastfeeding positions
Correct Answer: A
Rationale: Recognizing signs of infant dehydration is crucial for ensuring the health and well-being of infants. Dehydration can be life-threatening for infants if not addressed promptly. Proper diaper changing techniques, while important for hygiene, can be learned incrementally. The immunization schedule and breastfeeding positions are also essential topics, but identifying signs of dehydration takes precedence as it requires immediate attention to prevent serious complications.