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The home health nurse assesses an older adult client and observes possible signs of abuse. Which resource should the nurse use to guide their decision regarding reporting these suspicions?
- A. American Nurses Association (ANA) Code of Ethics.
- B. Nursing procedure manual.
- C. State law.
- D. Nurse practice act.
Correct Answer: C
Rationale: State law often provides specific guidelines on how and when to report suspected elder abuse. Therefore, it would be the most appropriate resource for the nurse to use in this situation.
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A nurse is preparing a nutrition class for a group of senior citizens at a local community center. The focus of the class is to highlight the quantity and types of fats in various foods. What is the most effective teaching method the nurse should employ?
- A. Exhibit posters showcasing different foods and discuss their fat content.
- B. Identify the most commonly consumed foods among the group and discuss each product's nutritional information.
- C. Screen a film about preparing tasty meals with low-fat ingredients.
- D. Request each senior to bring a food item for others to sample, then estimate the fat content of these foods.
Correct Answer: B
Rationale: Identifying the most commonly consumed foods among the group and discussing each product's nutritional information would be the most effective method. This approach is personalized and relevant, making the information more likely to be remembered and applied.
A student at an elementary school health fair reports having itchy circles on the lower legs. Which skin assessment finding should the nurse prioritize for immediate intervention?
- A. Patches of round lesions on both lower legs.
- B. Red ring-shaped lesions with normal skin in the center.
- C. Itchy, red, scaly patches with blisters that are draining.
- D. Several irritated circular bald, flaky scalp patches.
Correct Answer: C
Rationale: Itchy, red, scaly patches with blisters that are draining could be a sign of a serious skin infection such as cellulitis. This condition can spread quickly and become serious if not treated promptly, so it should be prioritized for immediate intervention.
Which community would benefit most from a lead poisoning education and screening program provided by the public health nurse?
- A. A community of older adults living in subsidized housing located near an airport.
- B. An urban community of young adults who frequently camp and hike in remote desert areas.
- C. A coastal community of mixed age groups who eat a diet high in fish and other seafood.
- D. A farming community where families with young children live primarily in 100-year-old farmhouses.
Correct Answer: D
Rationale: Families with young children living primarily in 100-year-old farmhouses would likely benefit most from a lead poisoning education and screening program. Older homes, particularly those built before 1978, often contain lead-based paint, which can pose a significant risk for lead poisoning, especially in young children.
Despite numerous instructions, an elderly patient with Parkinson's disease is unable to administer ophthalmic medication without assistance due to hand tremors. What is the best course of action for the nurse?
- A. Continue to reinforce the instructions to boost the patient's self-confidence.
- B. Determine if a family member is available and willing to administer the medication.
- C. Obtain a prescription for a visiting nurse to administer the medication twice a day.
- D. Document the patient's inability to administer the medication without assistance.
Correct Answer: B
Rationale: If a family member is available and willing to administer the medication, this could be an effective solution. The family member can be trained to administer the medication correctly, ensuring the patient receives their necessary treatment.
A healthcare provider requested a community health nurse to make weekly visits to a 10-year-old patient for weight reduction, monitoring fingerstick blood glucose levels, and severe headaches. The nurse is reviewing the patient's data. Which data warrants follow-up?
- A. The patient reports being teased by his friends for being “overweight.â€.
- B. The patient prefers solitary play situations.
- C. The patient lives with his mother and younger brother in subsidized housing in an inner city setting.
- D. The patient reports becoming easily short of breath.
Correct Answer: D
Rationale: The patient reporting that they become easily short of breath is a significant concern. Shortness of breath could indicate a number of health issues, including asthma, heart conditions, or other respiratory problems. This warrants immediate follow-up.