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The elementary school nurse has identified a problem requiring a secondary intervention. Which intervention should the nurse implement?
- A. Instruct on technique of 'stop, drop & roll' at assembly.
- B. Involve the parent teacher association (PTA) in a fund raising event for the new gym.
- C. Invite 1st grade parents to a 'Meet the Teachers' event.
- D. Send letters to parents regarding a recent lice infestation.
Correct Answer: D
Rationale: Sending letters about a lice infestation is a secondary prevention intervention, addressing an identified problem to control its spread.
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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.
The nurse is documenting the medical history of a young adult client who was recently diagnosed with type 1 diabetes mellitus. The client smokes 2 packs of cigarettes daily and the client's father died of a heart attack at the age of 45. Which annual screening is most important for the nurse include?
- A. Renal insufficiency.
- B. Peripheral neuropathy.
- C. Hyperlipidemia.
- D. Retinopathy.
Correct Answer: C
Rationale: Given the client's smoking habit and family history of early heart attack, screening for hyperlipidemia is critical to address cardiovascular risk, which is heightened by these factors and diabetes.
The community health nurse believes that immunization rates in a lower-socioeconomic section of the city are probably below the target set by the state health department. Which action should the nurse take first to intervene with this health problem?
- A. Review current epidemiological population data that might document a low immunization rate.
- B. Call a meeting of citizens to inform them of the importance of having their children immunized.
- C. Join a political action group that focuses attention on the issue in the local news media.
- D. Partner with a local children's hospital in setting up free 'shot' clinics in the neighborhood.
Correct Answer: A
Rationale: Reviewing epidemiological data confirms the extent of low immunization rates, providing a foundation for targeted interventions.
When assessing the health of a community, which is the most important information for the nurse to obtain?
- A. Mortality rate in the community.
- B. Expressed needs of community members.
- C. Life expectancy of clients in the community.
- D. Description of health problems by community leaders.
Correct Answer: B
Rationale: Expressed needs of community members provide direct insight into specific health concerns and priorities, ensuring interventions are relevant and effective.
While assessing a child at the community health clinic, the nurse notes that the toddler has multiple bruises on his legs and buttocks. After reporting suspected child abuse to the supervisor, which action should the nurse take next?
- A. Obtain a restraining order against the father.
- B. Encourage the mother to file a police report.
- C. Ask the child if his father ever spanks him.
- D. Refer the family to protective service agencies.
Correct Answer: D
Rationale: Referring to protective service agencies ensures a specialized investigation and intervention, prioritizing the child's safety and well-being.