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The home health nurse enters the home of a client, and the client's spouse immediately reports that the client cannot be awakened and appears to have taken an overdose of some medications. After determining that the client is unresponsive but is breathing and has a pulse, which action should the nurse take?
- A. Call 911 for emergency transport.
- B. Determine what medications were ingested.
- C. Contact the poison control center.
- D. Attempt to induce vomiting using a tongue blade.
Correct Answer: A
Rationale: Calling 911 ensures immediate medical intervention for an unresponsive client, critical to address a potential overdose.
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A migrant farm worker who lives in a mobile home with several other workers visits the Migrant Health Care Center. The client reports Increasing episodes of dizziness, headaches, abdominal cramps, and difficulty breathing. Which nursing action has the highest priority?
- A. Gather information about the client's recent exposure to pesticides.
- B. Obtain a blood sample to assess for possible lead paint exposure.
- C. Ask about the length of his workday and frequency of rest breaks.
- D. Determine the number and age of persons living in the mobile home.
Correct Answer: A
Rationale: Symptoms like dizziness and breathing difficulty suggest pesticide poisoning, a common risk for farm workers, requiring immediate investigation to guide treatment.
The nurse is teaching adults in the community about suicide awareness. Which information should the nurse include in the teaching?
- A. Suicide discussion is dangerous with people with depression.
- B. The majority of suicides occur in lower socioeconomic groups.
- C. Social support systems ensure suicide prevention.
- D. Severe life stresses at any age is a risk factor for suicide.
Correct Answer: D
Rationale: Severe life stresses are a well-established risk factor for suicide across all ages, critical for awareness and prevention efforts.
A client who recently returned from international travel presents to the clinic with high fever, chills, headache, and muscular aches. The healthcare provider suspects severe acute respiratory syndrome (SARS). To prevent transmission of the virus to others, which instruction is most important for the nurse to provide?
- A. Wear a N95 respirator mask during direct contact with others.
- B. Cover mouth and turn head when coughing
- C. Use meticulous hand washing technique.
- D. Discard all tissues used during coughing in a biohazard bag.
Correct Answer: A
Rationale: An N95 respirator mask is critical for preventing airborne transmission of SARS, offering superior protection compared to other measures like hand washing or tissue disposal.
The nurse is planning a health fair for high school students. Which assessment is most important for the nurse to obtain?
- A. Weight and height.
- B. Sexual activity.
- C. Immunization history.
- D. Visual acuity.
Correct Answer: B
Rationale: Assessing sexual activity is critical for high school students to address sexual health, STIs, and pregnancy risks, guiding tailored education and interventions.
A nurse is interested in studying the incidence of infant death in a particular city and wants to compare that city's rate to the state's rate. Which state resource should the nurse select to gather this information?
- A. Census data.
- B. Bureau of Vital Statistics.
- C. Disease registry.
- D. Department of Health.
Correct Answer: B
Rationale: The Bureau of Vital Statistics provides detailed data on vital events like deaths, making it the best resource for accurate infant mortality rates for city and state comparisons.