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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office visit, a nurse is obtaining an older adult client's vital signs and notices the caregiver is very quiet and withdrawn.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.
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Given the limited supply, the local health department is required to prioritize the distribution of influenza vaccines. Who should the public health nurse advise to return to the clinic when more vaccines are available?
- A. A 65-year-old aide working in a nursing home.
- B. An 8-year-old girl with poorly-controlled asthma.
- C. A 60-year-old client with diabetes and agoraphobia (fear of crowds).
- D. An 80-year-old resident in an Alzheimer's unit.
Correct Answer: C
Rationale: A 60-year-old client with diabetes is at increased risk for complications from influenza. However, their agoraphobia (fear of crowds) might make them less likely to be exposed to the virus compared to the other individuals. Therefore, they could be advised to return to the clinic when more vaccines are available.
After the first injection of the Hepatitis B Vaccine (HBV) series is administered to a group of healthcare workers, what advice should the nurse give to them?
- A. Suggest that they stay with someone for 10 hours post-injection.
- B. Advise them to bring a family member along for the final injection.
- C. Urge them to get all their family members vaccinated as soon as possible.
- D. Recommend annual blood tests to monitor their immunization levels.
Correct Answer: D
Rationale: Regular monitoring of immunization levels is important after receiving the HBV series. This is because healthcare workers are at a higher risk of exposure to Hepatitis B, and ensuring immunity is crucial for their safety.
A mother who is six weeks postpartum reports to the home health nurse that her milk supply seems to be diminishing. The nurse notices that the mother's 16-month-old child is constantly vying for her attention. What is the best advice the nurse can provide to help the mother with breastfeeding while also caring for a toddler?
- A. Have the 16-month-old child play in another room during breastfeeding.
- B. Read a book to the 16-month-old child while the mother is breastfeeding the infant.
- C. Encourage the toddler to watch TV while the mother is breastfeeding the baby.
- D. Give the toddler crayons and paper while the mother is breastfeeding the infant.
Correct Answer: B
Rationale: Reading a book to the 16-month-old child while the mother is breastfeeding the infant can be a practical solution. It allows the mother to attend to both children simultaneously, keeping the older child engaged while tending to the infant.
A patient is admitted to the emergency department with symptoms resembling the flu. What information should the nurse gather to rule out exposure to anthrax spores?
- A. Determine the patient's occupation.
- B. Identify the patient's personal contacts over the past week.
- C. Obtain a twenty-four-hour diet history.
- D. Inquire about previous vaccination for smallpox.
Correct Answer: A
Rationale: Anthrax is a serious disease caused by Bacillus anthracis, a bacterium that forms spores. Certain occupations, such as those involving livestock or animal products, may increase the risk of exposure to anthrax spores.
The nurse is screening for hypertension at a local health fair. A community resident has a blood pressure reading of 138/80 mm Hg. What interventions should the nurse implement for this client? Select all that apply.
- A. Encourage the client to “keep doing whatever you are doing.â€.
- B. Assess the client's lifestyle and other risk factors for hypertension.
- C. Ask the client about any current antihypertensive medications.
- D. Obtain another blood pressure reading to verify the first reading.
- E. Recommend further evaluation for possible pre-hypertension.
Correct Answer: B,C,D,E
Rationale: Assessing the client's lifestyle and other risk factors for hypertension, asking about current antihypertensive medications, obtaining another blood pressure reading to verify the first reading, and recommending further evaluation for possible pre-hypertension are all appropriate interventions for a client with a blood pressure reading of 138/80 mm Hg, which indicates possible pre-hypertension.