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On a day when the temperature is expected to drop to below freezing during the night, the nurse is asked to determine which homeless adults are most in need of the limited spaces that are available in a shelter. It is most important for which person to be admitted for the night?
- A. A young person with diabetes mellitus.
- B. A middle-aged person who has hypertension.
- C. An older person who is malnourished.
- D. An adult who was hit by a car 3 weeks ago.
Correct Answer: C
Rationale: A malnourished older person is most vulnerable to hypothermia due to impaired thermoregulation, making shelter critical to prevent cold-related illnesses.
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The school nurse who is reviewing immunization records of students who will start kindergarten within the next month notes that most of the students have only received one dose of the measles, mumps, rubella (MMR) vaccine. Which intervention should the nurse implement?
- A. Contact kindergarten parents to remind them that the second dose of MMR is due at the start of the school year.
- B. Send notices home with the children on the first day of class advising that MMR vaccine series must be completed.
- C. Note in student records that the second dose of the MMR vaccine should be administered prior to entering first grade.
- D. Speak at the next parent-teacher association meeting to teach parents the benefits of immunizing their children.
Correct Answer: A
Rationale: Contacting parents before the school year ensures timely MMR second-dose administration, meeting school entry requirements.
A graduate nursing student requests information, including laboratory findings and chest x-ray results, about all clients with symptoms of HINI influenza A who have been seen during the last month in a community health clinic. Which action should the charge nurse take?
- A. Provide the information for research purposes only.
- B. Ask the student to sign a standard waiver form.
- C. Obtain written authorization from clients to release the information.
- D. Ask if permission has been obtained from the research committee.
Correct Answer: C
Rationale: Obtaining client authorization ensures compliance with privacy laws like HIPAA, protecting client confidentiality.
The nurse is caring for a client with gonorrhea. The client reports having sex with multiple partners. Which response should the nurse provide?
- A. Emphasize that using safe sex practices removes the risk of sexually transmitted Infections (STIs)
- B. Clarify that all sexually transmitted infections (STIs) are transmitted through sexual intercourse.
- C. Discuss that partners without similar symptoms may not be infected.
- D. Instruct the client on the importance of notifying sexual partners.
Correct Answer: D
Rationale: Notifying sexual partners is critical to prevent further spread of gonorrhea, ensuring they are tested and treated, as asymptomatic individuals can still transmit the infection.
A client who recently returned from international travel presents to the clinic with high fever, chills, headache, and muscular aches. The healthcare provider suspects severe acute respiratory syndrome (SARS). To prevent transmission of the virus to others, which instruction is most important for the nurse to provide?
- A. Wear a N95 respirator mask during direct contact with others.
- B. Cover mouth and turn head when coughing
- C. Use meticulous hand washing technique.
- D. Discard all tissues used during coughing in a biohazard bag.
Correct Answer: A
Rationale: An N95 respirator mask is critical for preventing airborne transmission of SARS, offering superior protection compared to other measures like hand washing or tissue disposal.
The school health nurse observes that a large percentage of Hispanic children in the elementary school are overweight. Which screening program should the nurse choose to target the highest priority health concern for this population?
- A. Diabetes mellitus.
- B. Hypothyroidism.
- C. English proficiency.
- D. Iron deficiency anemia.
Correct Answer: A
Rationale: Overweight Hispanic children are at high risk for type 2 diabetes, making diabetes screening a priority to detect and manage this condition early, given its increasing prevalence in this population.