Nokea
The healthcare provider is inspecting the external eye structures of a client. Which finding is a normal racial variation?
- A. Blue sclerae.
- B. Brown macules on the sclerae.
- C. Slightly yellow sclerae in an African-American client.
- D. Conjunctival pallor.
Correct Answer: C
Rationale: The slightly yellow color of the sclera is a normal racial variation found in the African-American population. Blue sclerae (Choice A) are associated with osteogenesis imperfecta, not a normal racial variation. Brown macules on the sclerae (Choice B) may indicate issues like melanoma or melanosis but are not a normal racial variation. Conjunctival pallor (Choice D) suggests anemia or decreased blood flow but is not a normal racial variation.
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When examining sources for funding, which criteria should the nurse clarify about the program for the community group?
- A. a prescription from the healthcare provider for each visit made
- B. documentation of a skilled care service provided during the visit
- C. a copy of the client's health history and social security card
- D. a record of the preventive healthcare services provided during the visit
Correct Answer: C
Rationale: The correct answer is C because when seeking funding sources for a community outreach program, it is essential to clarify aspects related to the client's personal information, such as health history and identification details. This information helps in demonstrating the need for the program and understanding the target population. Choices A, B, and D are incorrect because they focus on clinical documentation, services provided during visits, and preventive healthcare services, which are not directly related to clarifying funding criteria about the program.
When caring for a client with a tracheostomy, which action should the nurse take first when performing tracheostomy care?
- A. Remove the inner cannula.
- B. Clean the stoma with normal saline.
- C. Change the tracheostomy ties.
- D. Suction the tracheostomy.
Correct Answer: D
Rationale: Suctioning the tracheostomy is the priority action because it ensures a patent airway before proceeding with any other tracheostomy care interventions. This step helps clear secretions and maintain airway patency, which is crucial for the client's respiratory status. Removing the inner cannula, cleaning the stoma, or changing the tracheostomy ties can follow once the airway is clear. Therefore, options A, B, and C are secondary actions compared to suctioning the tracheostomy.
A client with a history of coronary artery disease is admitted with chest pain. Which assessment finding requires immediate intervention?
- A. Heart rate of 90 beats per minute.
- B. Respiratory rate of 20 breaths per minute.
- C. Blood pressure of 130/80 mm Hg.
- D. Chest pain radiating to the left arm.
Correct Answer: D
Rationale: Chest pain radiating to the left arm is a classic symptom of a myocardial infarction (heart attack) in individuals with coronary artery disease. This finding indicates that the heart muscle may not be receiving adequate oxygen, which requires immediate intervention to prevent further damage or complications. The other assessment findings (heart rate of 90 beats per minute, respiratory rate of 20 breaths per minute, blood pressure of 130/80 mm Hg) are within normal limits and do not suggest an acute, life-threatening condition like myocardial infarction.
A community health nurse is evaluating the effectiveness of a diabetes management program. Which outcome indicates that the program is successful?
- A. increased attendance at diabetes education sessions
- B. reduced incidence of diabetes-related hospitalizations
- C. higher rates of blood glucose monitoring among participants
- D. greater knowledge of diabetes management techniques
Correct Answer: B
Rationale: The correct answer is B: reduced incidence of diabetes-related hospitalizations. This outcome is a strong indicator of successful diabetes management, as it suggests that participants are effectively controlling their condition and experiencing fewer severe complications that require hospitalization. Increased attendance at education sessions (choice A) may not directly correlate with improved health outcomes. While higher rates of blood glucose monitoring (choice C) are important, they alone may not reflect overall program success. Greater knowledge of diabetes management techniques (choice D) is valuable but does not directly measure the impact of the program on health outcomes like reduced hospitalizations.
A teenage boy with a history of recurring atopic dermatitis (eczema) tells the school nurse that he wants to play high school football. Which action should the nurse take?
- A. encourage the teenager to join the swim team instead of the football team
- B. notify the parents of the problems associated with perspiration for those with eczema
- C. tell the teenager to shower with a non-perfumed soap immediately after practice
- D. inform the football coach of the teenager's skin condition and its manifestations
Correct Answer: C
Rationale: The correct action for the nurse to take is to advise the teenager to shower with a non-perfumed soap immediately after practice. This recommendation can help reduce the risk of eczema flare-ups by removing sweat and irritants from the skin. Choice A is incorrect as it does not address the specific concerns related to eczema and football. Choice B, notifying the parents of perspiration problems, is not as direct as instructing the teenager on proper skincare. Choice D, informing the football coach, is not the most immediate and relevant action to address the teenager's individual needs.