Nokea
The healthcare provider is assessing a client with a suspected stroke. Which finding requires immediate intervention?
- A. Blood pressure of 160/90 mm Hg.
- B. Blood glucose level of 180 mg/dL.
- C. Difficulty speaking.
- D. Temperature of 99.8°F (37.7°C).
Correct Answer: C
Rationale: Difficulty speaking is a classic symptom of stroke, suggesting a potential blockage of blood flow to the brain. Prompt intervention is crucial to minimize brain damage. Elevated blood pressure (Choice A) may need management but is not the most urgent concern in this scenario. A blood glucose level of 180 mg/dL (Choice B) is slightly elevated but does not require immediate intervention for a suspected stroke. A temperature of 99.8°F (37.7°C) (Choice D) is within normal range and not a critical finding in this context.
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The nurse is developing a program to educate parents on the importance of childhood immunizations. Which topic should be prioritized?
- A. the benefits of immunizations
- B. the potential side effects of vaccines
- C. the immunization schedule
- D. ways to comfort children during vaccinations
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A school nurse is providing education on the importance of physical activity to elementary school students. Which activity is most appropriate for this age group?
- A. a lecture on the benefits of exercise
- B. an interactive game that involves physical movement
- C. a worksheet about different types of physical activities
- D. a video presentation on famous athletes
Correct Answer: B
Rationale: An interactive game that involves physical movement is the most appropriate activity for elementary school students when educating them on the importance of physical activity. This choice is preferred because it engages children directly in physical activity, making the learning experience fun, interactive, and memorable. Children at this age group learn best through hands-on experiences and active participation, which can be effectively facilitated through interactive games. Choices A, C, and D are less suitable for this age group as they do not actively involve children in physical movement or interactive learning experiences. A lecture may not be engaging enough for young children, a worksheet may not provide the required level of activity, and a video presentation may not offer the same level of direct engagement and participation as an interactive game.
When documenting assessment data, which statement should the nurse record in the narrative nursing notes?
- A. Client appears anxious.
- B. Client's skin is warm and dry.
- C. S1 murmur auscultated in supine position.
- D. Client is resting quietly.
Correct Answer: C
Rationale: The correct answer is C. When documenting assessment data in the narrative nursing notes, it is essential to include objective findings that are specific, clear, and descriptive. 'S1 murmur auscultated in supine position' provides a precise and objective assessment finding that can aid in accurately documenting the client's condition. Choices A, B, and D are more subjective statements that lack the specificity and clarity required for detailed documentation. 'Client appears anxious' and 'Client is resting quietly' are subjective observations, while 'Client's skin is warm and dry' is an objective finding but may not be as significant or relevant for comprehensive documentation as the auscultated murmur.
While screening all children in the third grade for head lice, the school nurse observes that one girl has a brownish thickening on her neck. Which action should the nurse take in response to this finding?
- A. review the child's medical folder for a list of allergies
- B. instruct the child's parents to begin treatment with
- C. advise the children's parents to obtain a medical evaluation of the child
- D. none of the above
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
During a home visit, a nurse observes an older client who is attempting to ambulate to the bathroom and notes that the client is unsteady and holds on to the furniture while refusing any assistance. Which action should the nurse implement?
- A. determine home navigational safety hazards
- B. maintain the client's privacy while in the bathroom
- C. recommend that the client obtain a walker
- D. encourage the client to obtain a medical alert device
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.