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The home health nurse visits a young adult client who has AIDS with Kaposi's sarcoma and peripheral neuropathies. The client's parents, who are the caretakers, tell the nurse that their child sleeps most of the time. The nurse assesses that the client is semi-conscious with stable vital signs, cries out in pain when turned or moved, has a fentanyl patch in place, and skin lesions that are closed and dried. Which intervention should the nurse implement?
- A. Give a complete bed bath to further assess the client.
- B. Remove the fentanyl patch as directed by prescription.
- C. Call for ambulance transportation to the hospital immediately.
- D. Discuss end-of-life decisions with the client's parents.
Correct Answer: D
Rationale: Discussing end-of-life decisions with the client's parents is the most appropriate intervention. The client is semi-conscious, sleeps most of the time, and is in significant pain. These symptoms suggest that the client's condition is deteriorating. It is important to have conversations about end-of-life care preferences and decisions to ensure that the client's wishes are respected and that the parents are prepared.
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The school nurse is conducting an audit of incident reports for adolescent students. Which finding is the best indication that the Healthy People 2030 objectives are being addressed?
- A. The number of requests for pregnancy testing is higher than last year.
- B. Decrease in the number of sick days.
- C. Increase in the number of students participating in physical education.
- D. Improvement in the overall health of the student population.
Correct Answer: D
Rationale: An improvement in the overall health of the student population is the best indication that the Healthy People 2030 objectives are being addressed. The Healthy People 2030 objectives aim to improve health and well-being nationwide. Therefore, an improvement in the overall health of the student population suggests that these objectives are being met.
In the event of a communication breakdown during a disaster, what actions should be taken?
- A. Contact a larger hospital to see how they handle disaster communication.
- B. Find out who did not follow the Communication tree.
- C. Have one person follow-up for all the hospital to see where the breakdown occurred.
- D. Confirm that all essential staff are on either the lockdown team or the relief team.
Correct Answer: D
Rationale: Confirming that all essential staff are on either the lockdown team or the relief team ensures that everyone knows their roles and responsibilities, which is crucial for effective communication during a disaster.
A 2-month-old infant contracts a disease through vertical transmission. Which situation should the nurse investigate further to ascertain how the infant might have been exposed to the disease?
- A. The infant received a scheduled immunization.
- B. The father fed the infant spoiled baby food.
- C. The mother is breastfeeding the infant.
- D. The infant was bitten by an infected mosquito.
Correct Answer: C
Rationale: Breastfeeding is a common method of vertical transmission. Certain infections in the mother can be passed to the infant through breast milk. Therefore, if a 2-month-old infant contracts a disease that could be transmitted vertically, it would be important to investigate if the mother could be the source of the infection.
A child living in an inner city setting reports that there are no playgrounds or sidewalks in their area, so their grandmother does not allow them to go outside after school. The grandmother cooks traditional meals every evening. The child describes how they love their grandmother's cooking, and they get to use homemade tortillas instead of forks to pick up their food to eat. The child reports that they become short of breath easily when they are playing with their friends, and they have “a lot†of headaches. On a scale of 0 to 10, with 10 being very happy, how would you rate your happiness with your weight? The child reports “2.â€. What do you believe is one thing that you can change to help you lose some of your weight?
- A. Increase physical activity
- B. Improve diet
- C. Reduce portion sizes
- D. All of the above
Correct Answer: D
Rationale: All of the above strategies - increasing physical activity, improving diet, and reducing portion sizes - are important for weight loss. They work together to create a calorie deficit, which is necessary for weight loss. It's also important to note that these strategies should be implemented as part of a sustainable lifestyle change, rather than a short-term diet.
The nurse is caring for a patient with the sexually transmitted infection (STI) gonorrhea. The patient reports having multiple sexual partners. What response should the nurse provide?
- A. Emphasize that practicing safe sex eliminates the risk of STIs.
- B. Instruct the patient on the importance of informing sexual partners.
- C. Discuss that partners without similar symptoms may not be infected.
- D. Clarify that all STIs are transmitted through sexual intercourse.
Correct Answer: B
Rationale: Informing sexual partners about a gonorrhea diagnosis is crucial. Gonorrhea is a highly contagious infection that can be transmitted through sexual contact. If a person has been diagnosed with gonorrhea, their sexual partners may also be at risk and should be informed so they can seek testing and treatment if necessary.