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The healthcare provider is assessing a client with a suspected myocardial infarction. Which finding requires immediate intervention?
- A. Chest pain radiating to the left arm.
- B. Shortness of breath.
- C. Nausea and vomiting.
- D. Diaphoresis.
Correct Answer: B
Rationale: Shortness of breath is a critical sign that can indicate heart failure or pulmonary edema, conditions that require immediate intervention in a client with a suspected myocardial infarction. Chest pain radiating to the left arm is a classic symptom of a myocardial infarction but may not necessitate immediate intervention compared to severe shortness of breath. Nausea and vomiting can be present in myocardial infarction but are not as urgent as shortness of breath. Diaphoresis, or sweating, is a common symptom of a myocardial infarction but may not be as immediately concerning as significant shortness of breath.
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A community health nurse is addressing the issue of domestic violence in the community. Which intervention should be prioritized?
- A. Providing education on the signs of domestic violence
- B. Setting up a support group for survivors
- C. Partnering with local law enforcement to increase patrols
- D. Creating a confidential hotline for reporting abuse
Correct Answer: D
Rationale: Creating a confidential hotline for reporting abuse is the most critical intervention when addressing domestic violence. A hotline offers a safe and confidential way for individuals experiencing abuse to report incidents, seek help, and access support services. This intervention prioritizes immediate safety and support for victims. Providing education on the signs of domestic violence (Choice A) is important for prevention but may not address the urgent needs of individuals currently experiencing abuse. Setting up a support group for survivors (Choice B) is valuable for emotional support but may not reach those who are not yet identified as survivors. Partnering with local law enforcement to increase patrols (Choice C) focuses more on the law enforcement response rather than providing a direct avenue for victims to seek help and support.
A client with a history of epilepsy is admitted with status epilepticus. Which medication should the nurse prepare to administer?
- A. Acetaminophen (Tylenol)
- B. Lorazepam (Ativan)
- C. Phenytoin (Dilantin)
- D. Carbamazepine (Tegretol)
Correct Answer: B
Rationale: In the management of status epilepticus, the initial medication of choice is a benzodiazepine such as lorazepam (Ativan) to rapidly terminate the seizure activity. Lorazepam acts quickly and effectively in stopping seizures. Phenytoin (Dilantin) is often used as a second-line agent for status epilepticus, and carbamazepine (Tegretol) is not typically indicated for the acute treatment of status epilepticus. Acetaminophen (Tylenol) is a pain reliever and antipyretic but is not used in the treatment of status epilepticus.
During a community health fair, the nurse conducts a blood pressure screening for a 60-year-old woman who has a blood pressure of 160/100 mm Hg. What should the nurse do first?
- A. Instruct the client to monitor her blood pressure at home
- B. Refer the client to her healthcare provider for further evaluation
- C. Educate the client on lifestyle changes to reduce blood pressure
- D. Recheck the blood pressure in 15 minutes
Correct Answer: B
Rationale: When encountering a high blood pressure reading at a community health fair, it is essential for the nurse to refer the client to her healthcare provider for further evaluation. This step ensures that the client receives a comprehensive assessment, diagnosis, and appropriate management plan. In this scenario, it is crucial to prioritize professional evaluation over self-monitoring, lifestyle education, or immediate rechecking of the blood pressure. Referral to a healthcare provider allows for timely intervention and ongoing monitoring of the client's blood pressure to prevent potential complications.
The healthcare provider is conducting a health assessment for a family living in a high-crime area. Which intervention should the healthcare provider prioritize to ensure the family's safety?
- A. providing information on local crime statistics
- B. teaching the family self-defense techniques
- C. helping the family develop a safety plan
- D. encouraging the family to move to a safer neighborhood
Correct Answer: C
Rationale: Developing a safety plan is the most appropriate intervention as it helps the family prepare for potential emergencies and enhances their overall sense of security. Providing information on local crime statistics may raise awareness but does not directly address safety planning. Teaching self-defense techniques may have limited effectiveness in a high-crime area where the family may face multiple threats. Encouraging the family to move to a safer neighborhood is not always feasible due to various reasons such as financial constraints or social ties to the current community.
The healthcare professional is preparing to administer a blood transfusion to a client with anemia. Which action is most important to prevent a transfusion reaction?
- A. Check the client's vital signs before starting the transfusion.
- B. Use a blood filter when administering the transfusion.
- C. Verify the blood type and Rh factor with another healthcare professional.
- D. Administer antihistamines before starting the transfusion.
Correct Answer: C
Rationale: Verifying the blood type and Rh factor with another healthcare professional is the most crucial action to prevent a transfusion reaction. Ensuring compatibility between the donor blood and the recipient is essential in preventing adverse reactions such as hemolytic transfusion reactions. Checking vital signs is important for monitoring the client during the transfusion process but does not directly prevent a transfusion reaction. Using a blood filter can help remove clots and debris but does not address the risk of a reaction due to blood type incompatibility. Administering antihistamines before the transfusion is not a standard practice to prevent transfusion reactions related to blood type incompatibility.