Nokea
A hospice nurse is talking with the partner of a client who is near death. The partner states, 'How will I go on without them? I already feel alone.' Which of the following actions should the nurse take?
- A. Express sympathy to the client's partner.
- B. Ask the client's partner if they need anything.
- C. Hug the client's partner.
- D. Reassure the client's partner that it will get better.
Correct Answer: A
Rationale: Correct Answer: A: Express sympathy to the client's partner.
Rationale: Expressing sympathy acknowledges the partner's emotions, validates their feelings, and shows empathy. It helps the partner feel heard and supported during a difficult time. This action focuses on the partner's emotional needs, offering comfort and understanding.
Summary:
B: Asking if the partner needs anything is helpful but may not address the emotional distress directly.
C: Hugging without consent may not be appropriate and could make the partner uncomfortable.
D: Reassuring without acknowledging the partner's feelings may come across as dismissive and invalidating.
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A community health nurse is planning a smoking cessation class. Which of the following factors will have the greatest effect on the success of the class?
- A. Presenter's teaching strategies
- B. Presenter's credibility
- C. Client's motivation
- D. Client's education level
Correct Answer: C
Rationale: The correct answer is C: Client's motivation. Motivation plays a crucial role in behavior change like quitting smoking. Without intrinsic motivation, clients may not fully engage in the class or follow through with quitting. Presenter's teaching strategies (A) and credibility (B) are important but not as impactful as client motivation. Client's education level (D) may influence comprehension but not motivation.
A nurse is working with a community health care team to devise strategies for preventing violence in the community. Which of the following interventions is an example of tertiary prevention?
- A. Presenting community education programs about stress management
- B. Developing resources for victims of abuse
- C. Urging community leaders to make nonviolence a priority
- D. Assessing for risk factors of intimate partner abuse during health examinations
Correct Answer: B
Rationale: The correct answer is B: Developing resources for victims of abuse. Tertiary prevention focuses on minimizing the impact of established disease or injury. By providing resources for victims of abuse, the community health care team is helping to support those who have already experienced violence, thus reducing potential long-term consequences. Choices A, C, and D are examples of primary and secondary prevention strategies, which aim to prevent violence before it occurs or identify and intervene early in cases of violence. These interventions are important but do not fall under tertiary prevention.
A school nurse is planning safety education for a group of adolescents. The nurse should give priority to which of the following topics as the leading cause of death for this age group?
- A. Sports injury prevention
- B. Motor vehicle safety
- C. Substance abuse prevention
- D. Gun safety
Correct Answer: B
Rationale: The correct answer is B: Motor vehicle safety. Adolescents are at a higher risk of motor vehicle accidents, making it the leading cause of death in this age group. This is due to factors like inexperience, risk-taking behaviors, and distractions while driving. Sports injury prevention (A) is important but not the leading cause of death. Substance abuse prevention (C) is significant but not the primary cause of death. Gun safety (D) is also crucial but not as prevalent as motor vehicle accidents.
Several nurses are developing a parish nurse group to help address the primary and secondary health care needs of the congregation. Which of the following services should the nurses plan to provide to the congregation?
- A. Organize an influenza immunization clinic with the American Red Cross
- B. Perform wound care in the home of members
- C. Provide end-of-life care for members who are terminal
- D. Facilitate discharge from the facility to the home
Correct Answer: A
Rationale: The correct answer is A: Organize an influenza immunization clinic with the American Red Cross. This service is important for promoting preventive health measures within the congregation. Influenza immunization helps reduce the spread of flu and protect vulnerable populations such as the elderly and young children. It aligns with the primary and secondary health care needs by focusing on prevention and early intervention. Providing wound care in members' homes (B) is more of a tertiary care service and may require specialized training and resources. End-of-life care (C) and discharge facilitation (D) are also important but may not directly address primary and secondary health care needs in this context.
A first response team is working at the location of a bombing incident. A nurse triaging a group of clients should give treatment priority to which of the following clients?
- A. A client who has superficial partial-thickness burn injuries over 5% of his body
- B. A client who has a femur fracture with a 2+ pedal pulse
- C. A client who is ambulatory and exhibits manic behavior
- D. A client who has a rigid abdomen with manifestations of shock
Correct Answer: D
Rationale: The correct answer is D: A client who has a rigid abdomen with manifestations of shock. This client should receive treatment priority because a rigid abdomen can indicate internal bleeding or organ damage, which are life-threatening conditions requiring immediate medical attention to prevent further complications. Manifestations of shock, such as hypotension and tachycardia, also indicate a critical condition that needs urgent intervention to stabilize the client's condition and prevent deterioration.
Choice A is incorrect because superficial partial-thickness burn injuries, although painful and requiring treatment, are not immediately life-threatening compared to internal injuries like in choice D. Choice B is incorrect as a femur fracture with a palpable pedal pulse indicates distal circulation is intact, making it a lower priority compared to the critical condition in choice D. Choice C is incorrect as manic behavior, while concerning, does not pose an immediate threat to the client's life compared to the potentially life-threatening conditions in choice D.