Nokea
The adolescent female comes to the school nurse of an intermediate school and tells the nurse she thinks she is pregnant. During the interview, the client states her father is the baby’s father. Which intervention should the nurse implement first?
- A. Complete a rape kit.
- B. Notify Child Protective Services.
- C. Call the parents to come to the school.
- D. Arrange for the client to go to a free clinic.
Correct Answer: B
Rationale: Alleged paternal incest requires immediate Child Protective Services notification as a mandatory reporter. Rape kit, parental contact, or clinic referral follow after ensuring safety.
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The client presents to the ED with acute vomiting after eating at a fast-food restaurant. There has not been any diarrhea. The nurse suspects botulism poisoning. Which nursing problem is the highest priority for this client?
- A. Fluid volume loss.
- B. Risk for respiratory paralysis.
- C. Abdominal pain.
- D. Anxiety.
Correct Answer: B
Rationale: Botulism causes progressive paralysis, including respiratory muscles, making respiratory paralysis the highest priority. Fluid loss, pain, and anxiety are secondary.
The nurse is assessing the client who suffered a near-drowning event. Which data require immediate intervention?
- A. The onset of pink, frothy sputum.
- B. An oral temperature of 97°F.
- C. An alcohol level of 100 mg/dL.
- D. A heart rate of 100 beats/min.
Correct Answer: A
Rationale: Pink, frothy sputum indicates pulmonary edema, a life-threatening complication requiring immediate intervention. Normal temperature, alcohol levels, and tachycardia are less urgent.
The ED receives a client involved in a motor-vehicle accident. The nurse notes a large hematoma on the right flank. Which intervention should the nurse implement first?
- A. Insert an indwelling urinary catheter.
- B. Take the vital signs every 15 minutes.
- C. Monitor the skin turgor every hour.
- D. Mark the edges of the bruised area.
Correct Answer: B
Rationale: Frequent vital signs assess for hypovolemia from potential internal bleeding (flank hematoma suggests renal or retroperitoneal injury). Catheter, skin turgor, and marking are secondary.
The nurse is teaching a class on bioterrorism and is discussing personal protective equipment (PPE). Which statement is the most important fact for the nurse to share with the participants?
- A. Health-care facilities should keep masks at entry doors.
- B. The respondent should be trained in the proper use of PPE.
- C. No single combination of PPE protects against all hazards.
- D. The EPA has divided PPE into four levels of protection.
Correct Answer: B
Rationale: Proper PPE training ensures safe use, critical for protection. Mask placement, hazard specificity, and EPA levels are secondary.
The nurse is teaching a class on biological warfare. Which information should the nurse include in the presentation?
- A. Contaminated water is the only source of transmission of biological agents.
- B. Vaccines are available and being prepared to counteract biological agents.
- C. Biological weapons are less of a threat than chemical agents.
- D. Biological weapons are easily obtained and result in significant mortality.
Correct Answer: D
Rationale: Biological weapons are easily obtained (e.g., anthrax) and cause high mortality, making them a significant threat. Water is not the only transmission route, vaccines are limited, and biological threats rival chemical ones.