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Four students come to the school clinic simultaneously, seeking help from the school nurse. In which order of priority should the nurse provide care to these students? (Arrange the client with the highest priority first, on top, and lowest priority last, on bottom.)
- A. A 12-year-old child with history of asthma who is wheezing and reporting shortness of breath.
- B. A 7-year-old child who has type 1 diabetes mellitus and is experiencing extreme hunger and shakiness
- C. A 10-year-old child with bleeding lacerations on both knees after falling in gym class.
- D. A 5-year-old child who is crying uncontrollably because of an incontinent bowel episode.
Correct Answer: A,B,C,D
Rationale: Asthma exacerbation (A) is life-threatening, requiring immediate intervention. Hypoglycemia (B) is urgent to prevent complications. Bleeding lacerations (C) need prompt care but are less critical. Incontinence (D) is least urgent, focusing on comfort after addressing medical emergencies.
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During a substance abuse class at an elementary school, a student says, 'My Dad used to drink one beer a day. Now he drinks at least a six-pack every day.' What does this child's description of the father indicate?
- A. The parent's judgment is likely too impaired to provide care for the child.
- B. Since the parent is increasing his alcohol intake, it is likely that he will soon begin using other addicting drugs.
- C. The parent is exhibiting tolerance to alcohol and must increase the amount to achieve the desired effect.
- D. The child is denying that there is a problem of alcohol abuse in the family.
Correct Answer: C
Rationale: The increase from one beer to a six-pack daily suggests tolerance, where the parent needs more alcohol to achieve the same effect, a hallmark of developing alcohol dependency.
A middle-aged client presents for an annual health visit at a community clinic. The client is 5 feet 10 inches (177.8 cm) tall, weighs 250 pounds (113.4 kg), and works as an accountant. The client has smoked at least one pack of cigarettes every day for the last 15 years. Which secondary prevention measure should the nurse recommend the client to follow?
- A. Smoking cessation.
- B. Compliance with antihypertensive and lipid lowering agents.
- C. Blood pressure and lipid screening.
- D. Increase physical activity and diet low in saturated fat.
Correct Answer: C
Rationale: Blood pressure and lipid screening are secondary prevention measures to detect cardiovascular issues early, critical for a smoker with obesity and high cardiovascular risk.
The nurse is documenting the medical history of a young adult client who was recently diagnosed with type 1 diabetes mellitus. The client smokes 2 packs of cigarettes daily and the client's father died of a heart attack at the age of 45. Which annual screening is most important for the nurse include?
- A. Renal insufficiency.
- B. Peripheral neuropathy.
- C. Hyperlipidemia.
- D. Retinopathy.
Correct Answer: C
Rationale: Given the client's smoking habit and family history of early heart attack, screening for hyperlipidemia is critical to address cardiovascular risk, which is heightened by these factors and diabetes.
The home health nurse enters the home of a client, and the client's spouse immediately reports that the client cannot be awakened and appears to have taken an overdose of some medications. After determining that the client is unresponsive but is breathing and has a pulse, which action should the nurse take?
- A. Call 911 for emergency transport.
- B. Determine what medications were ingested.
- C. Contact the poison control center.
- D. Attempt to induce vomiting using a tongue blade.
Correct Answer: A
Rationale: Calling 911 ensures immediate medical intervention for an unresponsive client, critical to address a potential overdose.
Community health nurses are particularly concerned with the spread of communicable diseases such as hepatitis A. Which group of Individuals should the nurse identify as being at greatest risk for contracting this type of hepatitis?
- A. Low income families living in cramped quarters.
- B. Sexually active persons with multiple partners.
- C. IV drug users who share needles.
- D. Those who have recently received a blood transfusion.
Correct Answer: A
Rationale: Hepatitis A spreads primarily through the fecal-oral route, often via contaminated food or water. Low-income families in cramped quarters are at higher risk due to increased exposure to unsanitary conditions and poor hygiene practices.