Nokea
Several nurses are developing a parish nurse group to help address the primary and secondary health care needs of the congregation. Which of the following services should the nurses plan to provide to the congregation?
- A. Organize an influenza immunization clinic with the American Red Cross
- B. Perform wound care in the home of members
- C. Provide end-of-life care for members who are terminal
- D. Facilitate discharge from the facility to the home
Correct Answer: A
Rationale: The correct answer is A: Organize an influenza immunization clinic with the American Red Cross. This service is important for promoting preventive health measures within the congregation. Influenza immunization helps reduce the spread of flu and protect vulnerable populations such as the elderly and young children. It aligns with the primary and secondary health care needs by focusing on prevention and early intervention. Providing wound care in members' homes (B) is more of a tertiary care service and may require specialized training and resources. End-of-life care (C) and discharge facilitation (D) are also important but may not directly address primary and secondary health care needs in this context.
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A nurse is providing education to a group of adolescents who are pregnant and attending high school. Which of the following information should the nurse include in their teaching?
- A. The need for supplemental folic acid is greatest during the third trimester
- B. The incidence of high birth weight infants is higher in adolescent pregnancy
- C. Pregnant adolescents need to gain less weight than adult mothers
- D. Caffeinated beverages should be replaced with caffeine-free beverages
Correct Answer: D
Rationale: The correct answer is D: Caffeinated beverages should be replaced with caffeine-free beverages. Pregnant adolescents should limit their caffeine intake as excessive caffeine can lead to complications during pregnancy. Caffeine can cross the placenta and affect the baby's heart rate and sleep patterns. It is important for pregnant adolescents to switch to caffeine-free beverages to ensure the health and well-being of both the mother and baby.
A: The need for supplemental folic acid is not specific to the third trimester, it is important throughout pregnancy.
B: The incidence of high birth weight infants is not necessarily higher in adolescent pregnancy compared to adult mothers.
C: Pregnant adolescents actually need to gain weight within the recommended range, similar to adult mothers, to support fetal growth and development.
A nurse is working in a shelter following a disaster. Which of the following is the priority action for the nurse to take?
- A. Create diversionary activities for children
- B. Address the physical needs of clients
- C. Help clients gather needed supplies
- D. Explore feelings the clients are experiencing
Correct Answer: B
Rationale: The correct answer is B: Address the physical needs of clients. This is the priority action because in a disaster setting, ensuring the basic physical needs of clients such as food, water, shelter, and medical care takes precedence to ensure their survival and well-being. Without addressing these needs first, the clients' health and safety could be compromised. Creating diversionary activities for children (A), helping clients gather supplies (C), and exploring clients' feelings (D) are important but secondary to addressing immediate physical needs. It is crucial to prioritize basic survival needs before addressing emotional or social needs in a disaster situation.
A home health nurse is scheduled for a first-time visit to a client. Which of the following should the nurse perform first?
- A. Blood pressure screening
- B. Mental status examination
- C. Review of the neighborhood
- D. Family history
Correct Answer: C
Rationale: The correct answer is C: Review of the neighborhood. This should be performed first to assess the safety and environment of the client's home, ensuring the nurse's safety and the ability to provide care effectively. It helps identify potential hazards or resources in the community. Blood pressure screening (A) can wait until after ensuring a safe environment. Mental status examination (B) is important but can be conducted after assessing the neighborhood. Family history (D) is not a priority for the first visit.
A school nurse is assessing a child who has been stung by a bee. The child's hand is swelling, and the nurse notes that the child is allergic to insect stings. Which of the following findings should the nurse expect if the child develops anaphylaxis? (SATA)
- A. Bradycardia
- B. Nausea
- C. Hypertension
- D. Urticaria
- E. Stridor
Correct Answer: B, D, E
Rationale: Correct Answer: B, D, E
Rationale:
1. Nausea: Anaphylaxis can cause gastrointestinal symptoms like nausea due to the release of inflammatory mediators.
2. Urticaria: Anaphylaxis commonly presents with hives (urticaria) as a manifestation of allergic reaction.
3. Stridor: Anaphylaxis can lead to upper airway swelling, causing stridor due to compromised breathing.
Summary of Incorrect Choices:
A. Bradycardia: Anaphylaxis typically causes tachycardia due to the body's response to the allergen.
C. Hypertension: Anaphylaxis usually results in hypotension due to vasodilation and increased vascular permeability.
A newly hired occupational health nurse is assessing hazards in the work environment. Which of the following actions will help the nurse detect potential physical hazards?
- A. Survey workers about job-related emotional stress.
- B. Measure the noise levels at various locations in the facility.
- C. Identify industrial toxins that are present in the environment.
Correct Answer: B
Rationale: The correct answer is B: Measure the noise levels at various locations in the facility. This action will help the nurse detect potential physical hazards because excessive noise can lead to hearing damage and other health issues. By measuring noise levels, the nurse can identify areas where noise levels exceed safe limits and implement control measures.
Surveying workers about emotional stress (Choice A) is important for psychological well-being but does not directly address physical hazards. Identifying industrial toxins (Choice C) is important for chemical hazards, not physical hazards related to noise. The other choices are not provided, but measuring noise levels is the most relevant action for detecting physical hazards in this scenario.