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During a home visit, the nurse observes that an elderly client has a cluttered living environment and poor lighting. What should the nurse do first?
- A. suggest the client hires a cleaning service
- B. assist the client in organizing the living space
- C. assess the client's risk for falls
- D. provide the client with information on home safety
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A female client is admitted with a tentative diagnosis of Guillain-Barre syndrome. Which finding is most important for the nurse to report to the healthcare provider?
- A. Facial weakness and difficulty speaking.
- B. Decreased deep tendon reflexes in the legs.
- C. Inability to move the eyes.
- D. Respiratory distress and cyanosis.
Correct Answer: B
Rationale: In Guillain-Barre syndrome, decreased deep tendon reflexes are a critical finding that may indicate impending respiratory failure. This is due to the involvement of the peripheral nervous system affecting the muscles, including those involved in breathing. Reporting decreased deep tendon reflexes promptly is essential to prevent respiratory compromise. Facial weakness, difficulty speaking, and inability to move the eyes are common manifestations of Guillain-Barre syndrome but are not as immediately concerning as respiratory distress and impending respiratory failure.
When assessing the health of a community, what is the most important information for the nurse to obtain?
- A. life expectancy of clients in the community
- B. mortality rates in the community
- C. description of health problems by community leaders
- D. expressed needs of community members
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A school nurse is organizing a vaccination clinic for middle school students. Which vaccine is most important for the nurse to include?
- A. hepatitis B
- B. tetanus, diphtheria, and pertussis (Tdap)
- C. varicella
- D. measles, mumps, and rubella (MMR)
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is teaching a group of new mothers about infant care. Which topic should the nurse prioritize?
- A. signs of infant dehydration
- B. proper diaper changing techniques
- C. immunization schedule
- D. breastfeeding positions
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse notices that the influenza immunization rate is much lower for certain demographic groups than for others. Which intervention is likely to be most useful in increasing the rates of immunization in the underserved community groups?
- A. designated clinics conveniently located in target neighborhoods
- B. reports decreasing influenza rates during times of greatest prevalence
- C. legislative proposals that mandate influenza vaccinations for all
- D. radio announcements about the availability of the influenza vaccine
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.