Nokea
The community health nurse is educating new nurses on the spread of infectious diseases. The nurse utilizes which of the following approaches to explain the factors that allow the reproduction and spread of infectious disease?
- A. Epidemiologic triangle
- B. Levels of prevention
- C. Natural history of disease
- D. Health Promotion
Correct Answer: A
Rationale: The correct answer is A: Epidemiologic triangle. This model explains infectious disease spread by considering the interactions between the host, agent, and environment. Host factors include susceptibility to the disease, agent factors refer to the infectious microorganism, and environmental factors influence transmission. This approach helps new nurses understand the complex interplay of factors leading to disease transmission. Choices B, C, and D are incorrect because they do not specifically address the factors involved in the reproduction and spread of infectious diseases. Level of prevention refers to actions taken to prevent disease, natural history of disease focuses on disease progression, and health promotion aims to improve overall health but does not directly explain disease spread.
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A nurse is caring for a client brought to the Emergency Department as one of the first victims of a train accident. The nurse assesses the client, noting a respiratory rate of 38, a weak, rapid pulse, and uncontrolled bleeding. Using NATO guidelines, the nurse assigns which priority tag?
- A. Red tag
- B. Black tag
- C. Green tag
- D. Yellow tag
Correct Answer: A
Rationale: The correct answer is A: Red tag. The nurse assigns a red tag based on the assessment findings of a high respiratory rate, weak rapid pulse, and uncontrolled bleeding, indicating a critically injured patient requiring immediate intervention. Red tag signifies priority 1 according to NATO guidelines, indicating the need for immediate life-saving interventions. Other choices are incorrect because Black tag (B) is used for deceased or non-salvageable patients, Green tag (C) for minor injuries, and Yellow tag (D) for delayed or non-urgent care. In this scenario, the patient's critical condition necessitates the assignment of a red tag for prompt and urgent care.
A nurse is assessing a client who was brought into the emergency room following a seizure. The nurse suspects the client may have meningococcal meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next?
- A. Administer an antipyretic
- B. Complete a vascular assessment
- C. Assess the cranial nerves
- D. Decrease environmental stimuli
Correct Answer: C
Rationale: The correct answer is C: Assess the cranial nerves. Meningococcal meningitis can affect the cranial nerves, leading to symptoms such as photophobia, altered mental status, and cranial nerve deficits. Assessing the cranial nerves will help the nurse to further evaluate the client's neurological status and identify any abnormalities that may indicate the severity of the condition. Administering an antipyretic (A) may help reduce fever but does not address the underlying issue. Completing a vascular assessment (B) is not a priority in this situation. Decreasing environmental stimuli (D) may be helpful for a seizure but is not the next priority after implementing droplet precautions.
A nurse is teaching a client who has a new prescription for Sumatriptan (Imitrex) tablets to treat migraine headaches. Which of the following instructions should the nurse include?
- A. Chew tablet well before swallowing
- B. If you experience chest pain, call your physician immediately
- C. Take daily to prevent headaches
- D. Repeat dose in 1 hour for unrelieved headache
Correct Answer: B
Rationale: The correct answer is B: If you experience chest pain, call your physician immediately. This is crucial because Sumatriptan can sometimes cause chest pain or tightness as a side effect, which could indicate a serious issue like a heart problem. Instructing the client to contact their physician immediately ensures prompt medical attention if such symptoms occur, potentially preventing a serious complication. Choices A, C, and D are incorrect. A: Chewing Sumatriptan tablets is not recommended as it may alter the drug's absorption rate. C: Sumatriptan is not meant to be taken daily for headache prevention; it is used for acute migraine attacks. D: Repeating the dose in 1 hour is not advised as it can increase the risk of side effects and medication overuse headaches.
A nurse is caring for a client who has Parkinson's disease and is starting to display bradykinesia. Which of the following is an appropriate action by the nurse?
- A. Place the client on a low-protein, low-calorie diet
- B. Teach the client to walk more quickly when ambulating
- C. Complete passive range-of-motion exercises daily
- D. Give the patient extra time to perform activities
Correct Answer: D
Rationale: The correct answer is D: Give the patient extra time to perform activities. Bradykinesia is a common symptom of Parkinson's disease characterized by slow movement. By giving the patient extra time to perform activities, the nurse can accommodate the decreased speed of movement associated with bradykinesia, promoting independence and preventing frustration. Placing the client on a low-protein, low-calorie diet (A) is not relevant to addressing bradykinesia. Teaching the client to walk more quickly (B) may not be feasible due to the physical limitations caused by the condition. Completing passive range-of-motion exercises daily (C) may be beneficial for maintaining mobility but does not directly address bradykinesia. Giving the patient extra time to perform activities (D) is the most appropriate action as it supports the client's autonomy and helps manage the symptom effectively.
A nurse is working with the hospital disaster plan with the emergency operations committee. The nurse is aware that nursing is involved in which components of the disaster plan? SELECT ALL THAT APPLY
- A. Identification of resources to meet anticipated needs
- B. Participation in comprehensive annual drills
- C. Internal and external communications
- D. Performing duties outside the typical job description
- E. Development of a decontamination plan
Correct Answer: A,B,C,E
Rationale: The correct choices are A, B, C, and E. A: Nurses identify resources needed during a disaster to meet patient needs. B: Nurses participate in drills to practice response protocols. C: Nurses play a role in both internal communication within the healthcare facility and external communication with outside agencies. E: Nurses are involved in the development of decontamination plans to ensure safety. D: While nurses may perform duties outside their normal scope during a disaster, it is not a specific component of the disaster plan. Therefore, it is incorrect.