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In conducting a health assessment for a family with a history of cardiovascular disease, which family member should be prioritized for further evaluation and intervention?
- A. a 45-year-old father who smokes and has high cholesterol
- B. a 17-year-old daughter who is overweight and inactive
- C. a 50-year-old mother with a history of hypertension
- D. a 12-year-old son who has a normal weight and is active
Correct Answer: A
Rationale: The 45-year-old father who smokes and has high cholesterol is at a higher risk for cardiovascular disease due to multiple risk factors. Smoking and high cholesterol are significant contributors to the development of cardiovascular issues. Prioritizing his evaluation and intervention is crucial to address these modifiable risk factors. The other family members, though they may have risk factors as well, do not present with the same level of immediate risk based on the information provided.
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The healthcare professional is developing a program to educate parents on childhood safety. Which topic should be prioritized?
- A. the benefits of car seats
- B. how to childproof the home
- C. the importance of helmet use
- D. ways to prevent drowning
Correct Answer: B
Rationale: Prioritizing the topic of how to childproof the home is crucial as it provides a holistic approach to safeguarding children from various injuries within the home environment. Childproofing the home addresses a wide range of hazards such as falls, burns, poisoning, and choking incidents. While topics like the benefits of car seats, the importance of helmet use, and ways to prevent drowning are important, childproofing the home covers a broader spectrum of safety measures that can significantly reduce the risk of injuries for children.
A first-grade boy is sent to the school nurse after he fainted while playing tag during recess. When he arrives in the clinic he is alert and oriented and his vital signs include temperature of 97.8°F, pulse 96 bpm, respirations 15 breaths/minute, and blood pressure 80/56 mmHg. Which intervention is most important for the nurse to implement?
- A. request transport of the child to his pediatrician's office
- B. call the child's parents and send him home for the day
- C. compare the child's body mass index to normal values
- D. measure the child's pulse and blood pressure every 15 minutes
Correct Answer: D
Rationale: In this scenario, the most important intervention for the nurse to implement is to measure the child's pulse and blood pressure every 15 minutes. The child experienced a syncopal episode (fainting) which could be due to various reasons, including dehydration or cardiac issues. Monitoring vital signs frequently will help detect any changes that may indicate underlying health issues. Requesting transport to the pediatrician's office or sending the child home without continuous monitoring may not provide immediate assessment and intervention. Comparing the child's body mass index to normal values is not relevant in addressing the immediate concern of monitoring vital signs after a syncopal episode.
The nurse is caring for a client with hyperthyroidism. Which assessment finding requires immediate intervention?
- A. Heart rate of 100 beats per minute.
- B. Blood pressure of 150/90 mm Hg.
- C. Respiratory rate of 24 breaths per minute.
- D. Weight loss of 5 pounds in one week.
Correct Answer: D
Rationale: Weight loss of 5 pounds in one week in a client with hyperthyroidism is concerning as it may indicate severe hypermetabolism, leading to potential complications such as cardiac arrhythmias, muscle weakness, and other metabolic disturbances. Rapid weight loss in hyperthyroidism indicates an accelerated metabolic rate and increased energy expenditure, which can be detrimental to the client's health. The other assessment findings (heart rate of 100 beats per minute, blood pressure of 150/90 mm Hg, respiratory rate of 24 breaths per minute) are commonly seen in clients with hyperthyroidism and may not necessarily require immediate intervention unless they are significantly outside the normal range or causing distress to the client.
The nurse identifies a client's needs and formulates the nursing problem of 'Imbalance nutrition: Less than body requirements, related to mental impairment and decreased intake, as evidenced by increasing confusion and weight loss of more than 30 pounds over the last 6 months.' Which short-term goal is best for this client?
- A. Eat 50% of six small meals each day by the end of the week.
- B. Gain 5 pounds by the end of the month.
- C. Have increased caloric intake.
- D. Show improved nutritional status.
Correct Answer: A
Rationale: The correct short-term goal for the client in this scenario is option A: 'Eat 50% of six small meals each day by the end of the week.' This goal is specific, measurable, and time-bound, which aligns with the SMART criteria for goal setting in nursing care. It addresses the client's nutritional needs directly, focusing on increasing meal frequency to meet body requirements and counteract weight loss. Option B, 'Gain 5 pounds by the end of the month,' is not as suitable as it lacks specificity and a short-term timeline, making it less achievable within the immediate care plan. Option C, 'Have increased caloric intake,' is vague and does not provide a measurable target for the client to work towards. Option D, 'Show improved nutritional status,' is a broad goal that lacks the specificity needed for effective short-term goal setting in nursing care. Therefore, option A is the most appropriate choice for this client's short-term goal.
The healthcare provider is assessing a client who has returned from hemodialysis. Which finding requires immediate intervention?
- A. Weight gain of 1 pound.
- B. Dizziness.
- C. Fatigue.
- D. Muscle cramps.
Correct Answer: D
Rationale: After hemodialysis, muscle cramps can indicate an electrolyte imbalance, such as low potassium or magnesium levels, which requires immediate intervention to prevent potential complications like cardiac arrhythmias. Weight gain of 1 pound, dizziness, and fatigue are common post-hemodialysis symptoms that may not necessarily require immediate intervention unless they are severe or persisting.