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During a home visit, the nurse observes that an elderly client has numerous bruises on her arms and appears fearful of her caregiver. What should the nurse do first?
- A. report the findings to adult protective services
- B. ask the client how she got the bruises
- C. document the observations in the client's medical record
- D. discuss the observations with the caregiver
Correct Answer: B
Rationale: The initial step for the nurse should be to ask the client how she got the bruises. This approach allows the nurse to directly assess the situation, gather information from the client, and potentially uncover signs of abuse. Reporting to adult protective services should come after obtaining more details from the client to ensure appropriate action. Documenting the observations is important but should follow gathering information from the client. Discussing the observations with the caregiver may not be appropriate as the caregiver could be the source of abuse, and involving them first may jeopardize the client's safety.
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The nurse is conducting a process evaluation of a prevention education program for older adults who are at risk for substance abuse. Which data source provides the information the nurse needs to conduct this process evaluation?
- A. client's score on an alcohol screening instrument
- B. results of a urine drug and alcohol screen
- C. most recent community census data
- D. documentation of client education in the nursing record
Correct Answer: D
Rationale: The correct answer is D. Documentation of client education in the nursing record provides information on the implementation and progress of the educational program, which is crucial for evaluating its process. Choices A and B focus on individual client assessment rather than program evaluation. Choice C, community census data, is not directly related to evaluating the process of the prevention education program for older adults at risk for substance abuse.
A public health nurse is working with a community to improve vaccination rates. Which intervention is most likely to be effective?
- A. Setting up vaccination clinics in accessible locations
- B. Distributing flyers with information about vaccines
- C. Offering incentives for getting vaccinated
- D. Partnering with local businesses to promote vaccination
Correct Answer: A
Rationale: Setting up vaccination clinics in accessible locations is the most effective intervention to improve vaccination rates. This intervention ensures easy access to vaccination services for community members, removing barriers such as transportation or time constraints. Distributing flyers (Choice B) may increase awareness but may not directly address access issues. Offering incentives (Choice C) might temporarily boost vaccination rates but may not lead to sustained behavior change. Partnering with local businesses (Choice D) could be beneficial for promotion but may not directly impact vaccination accessibility.
The healthcare provider is developing a community outreach program to address childhood obesity. Which intervention should the healthcare provider implement first?
- A. conduct a survey to assess dietary habits and physical activity levels
- B. develop educational materials on healthy eating and exercise
- C. partner with local schools to promote physical activity programs
- D. organize community events that encourage healthy lifestyle choices
Correct Answer: A
Rationale: Conducting a survey to assess dietary habits and physical activity levels should be the initial step in developing a community outreach program to address childhood obesity. By gathering data through a survey, the healthcare provider can identify specific needs, preferences, and challenges within the community. This information is crucial for designing tailored interventions that are more likely to be effective. Developing educational materials (Choice B) can come after understanding the community's needs through the survey. Partnering with local schools (Choice C) and organizing community events (Choice D) are important strategies but should be planned based on the data obtained from the survey to ensure relevance and impact.
The healthcare professional is planning a health education workshop for a group of adolescents on the dangers of substance abuse. Which strategy is most likely to be effective?
- A. showing videos of the effects of substance abuse
- B. inviting individuals in recovery to share their stories
- C. providing statistical data on substance abuse
- D. distributing brochures on substance abuse prevention
Correct Answer: B
Rationale: Inviting individuals in recovery to share their stories is the most effective strategy for educating adolescents about the dangers of substance abuse. Personal stories have a significant impact as they provide real-life examples of the consequences of substance abuse, making the information more relatable and emotionally engaging. This approach can evoke empathy, create a deeper understanding of the risks involved, and potentially deter adolescents from experimenting with substances. Showing videos of the effects of substance abuse (choice A) may be impactful, but personal narratives often have a stronger emotional connection. Providing statistical data (choice C) may not resonate as strongly with adolescents as personal stories. Distributing brochures (choice D) is informative but may not have the same emotional impact and engagement as hearing firsthand experiences.
The nurse is providing care for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which laboratory result requires immediate intervention?
- A. Serum sodium of 140 mEq/L.
- B. Serum potassium of 4.5 mEq/L.
- C. Serum osmolality of 280 mOsm/kg.
- D. Serum sodium of 130 mEq/L.
Correct Answer: D
Rationale: The correct answer is D: Serum sodium of 130 mEq/L. In SIADH, there is excess release of antidiuretic hormone leading to water retention and dilutional hyponatremia. A serum sodium level of 130 mEq/L indicates severe hyponatremia, which can result in neurological symptoms, such as confusion, seizures, and coma. Therefore, immediate intervention is required to prevent further complications. Choice A, a serum sodium of 140 mEq/L, is within the normal range and does not require immediate intervention. Choice B, serum potassium of 4.5 mEq/L, is also within the normal range and is not directly related to SIADH. Choice C, serum osmolality of 280 mOsm/kg, is a measure of the concentration of solutes in the blood and may not be the most critical parameter to address in a client with SIADH and severe hyponatremia.