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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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A migrant farm worker who lives in a mobile home with several other workers visits the Migrant Health Care Center. The client reports Increasing episodes of dizziness, headaches, abdominal cramps, and difficulty breathing. Which nursing action has the highest priority?
- A. Gather information about the client's recent exposure to pesticides.
- B. Obtain a blood sample to assess for possible lead paint exposure.
- C. Ask about the length of his workday and frequency of rest breaks.
- D. Determine the number and age of persons living in the mobile home.
Correct Answer: A
Rationale: Symptoms like dizziness and breathing difficulty suggest pesticide poisoning, a common risk for farm workers, requiring immediate investigation to guide treatment.
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.
A toddler is brought by a parent to the health department for scheduled immunizations. The toddler clings to the caregiver and cowers when approached. Which assessment warrants immediate intervention by the nurse?
- A. Small bruises on the lower extremities.
- B. A one-inch laceration across center of forehead.
- C. Refusal to answer simple questions.
- D. Several dime-sized circular burns on the back.
Correct Answer: D
Rationale: Circular burns are suggestive of abuse, requiring immediate intervention to ensure the child's safety and further investigation.
Which annual screening should the nurse include when planning an eye health program at a preschool?
- A. Glaucoma.
- B. Red light reflex.
- C. Visual acuity.
- D. Conjunctivitis.
Correct Answer: C
Rationale: Visual acuity screening is essential for preschoolers to detect vision issues like amblyopia or refractive errors that could impact development and learning, making it the priority for annual eye health programs.
A school nurse is developing a health risk screening protocol for use at an elementary school. Which information is most important for the nurse to include in this protocol?
- A. Long bone density testing.
- B. Annual flu vaccination status.
- C. Weight and height measurement.
- D. Serum total cholesterol level.
Correct Answer: C
Rationale: Weight and height measurements are essential for assessing growth, detecting malnutrition or obesity, and monitoring overall health in elementary students.