Nokea
The nurse is assessing a newborn the day after birth. A high-pitched cry, irritability, and lack of interest in feeding are noted. The mother signed her own discharge against medical advice. What intervention is appropriate nursing care?
- A. Reduce the environmental stimuli
- B. Offer formula every 2 hours
- C. Talk to the newborn while feeding
- D. Rock the baby frequently
Correct Answer: A
Rationale: The correct intervention is to reduce the environmental stimuli. In this scenario, the newborn is displaying signs of overstimulation and distress, which can be exacerbated by environmental factors. Offering formula every 2 hours (Choice B) may not address the underlying issue of overstimulation. Talking to the newborn while feeding (Choice C) and rocking the baby frequently (Choice D) may further stimulate the newborn, which is not appropriate in this case.
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In a well-child clinic, the nurse examines many children daily. Which of the following toddlers requires further follow-up?
- A. A 13-month-old who is unable to walk
- B. A 20-month-old who is only using 2 and 3 word sentences
- C. A 24-month-old who cries during examination
- D. A 30-month-old who is only drinking from a sip cup
Correct Answer: D
Rationale: The correct answer is D because a 30-month-old should have developed the skill to drink from a regular cup by this age. Drinking from a sip cup at this stage may indicate a delay in development. Choices A, B, and C are not as concerning as they can be within the range of normal development. A 13-month-old not walking yet, a 20-month-old using 2 and 3 word sentences, and a 24-month-old crying during examination are all behaviors that can fall within the spectrum of typical development for their respective ages.
During the beginning shift assessment of a client with asthma who is receiving oxygen via nasal cannula at 2 liters per minute, the nurse would be most concerned about which unreported finding?
- A. Pulse oximetry reading of 89%
- B. Crackles at the base of the lungs on auscultation
- C. Rapid shallow respirations with intermittent wheezes
- D. Excessive thirst with a dry cracked tongue
Correct Answer: C
Rationale: Rapid, shallow respirations with intermittent wheezes are concerning as they indicate a potential worsening of the client's asthma. This finding suggests airway narrowing, which can lead to respiratory failure. Immediate intervention is required to address this respiratory distress. A pulse oximetry reading of 89% is low and indicates hypoxemia, but the respiratory pattern described in option C takes priority as it directly reflects the client's respiratory status. Crackles at the base of the lungs suggest fluid accumulation, which is important but not as immediately critical as the respiratory distress in asthma. Excessive thirst and a dry cracked tongue may indicate dehydration, which is relevant but not as urgent as the respiratory compromise presented in option C.
What influences health status?
- A. lifestyle choices and community resources
- B. availability of health technology like diagnostic machines
- C. presence of toxic environmental conditions
- D. all of the above
Correct Answer: D
Rationale: Health status is influenced by a combination of lifestyle choices, community resources, health technology like diagnostic machines, and environmental conditions. Each of these factors plays a role in determining an individual's overall health. Choice A is correct as lifestyle choices (such as diet, exercise, and smoking habits) and access to community resources (like healthcare facilities, support groups, and recreational spaces) are important determinants of health. Choice B is correct as the availability of health technology, including diagnostic machines, can impact early detection and treatment of health conditions. Choice C is correct as exposure to toxic environmental conditions (such as pollution, contaminated water, or hazardous waste) can have adverse effects on health. Therefore, the correct answer is D because all of these factors collectively influence health status.
What role does a community health nurse play in disaster management?
- A. Providing direct patient care
- B. Conducting research on disaster impacts
- C. Coordinating emergency response efforts
- D. Developing new healthcare policies
Correct Answer: C
Rationale: Community health nurses are primarily responsible for coordinating emergency response efforts during disasters. This involves organizing and implementing strategies to address the health needs of the community in crisis situations. Providing direct patient care (Choice A) is often carried out by other healthcare professionals such as doctors and paramedics during disasters. Conducting research on disaster impacts (Choice B) is important for understanding the effects of disasters but is not the primary role of a community health nurse. Developing new healthcare policies (Choice D) is typically the responsibility of policymakers and public health officials rather than community health nurses.
The RN at a migrant health center notes an increased incidence of dermatitis in seasonal farm workers at a local fruit farm. In response to this finding, what is the most important information for the RN to obtain as part of the community assessment?
- A. Availability of clean fresh water to wash hands after work.
- B. Proper housing
- C. Access to health care services
- D. Access to transportation
Correct Answer: A
Rationale: The correct answer is A: Availability of clean fresh water to wash hands after work. Proper hand hygiene, including washing hands with clean water, is crucial in preventing dermatitis, especially in farm workers who are exposed to potential irritants in their work environment. While proper housing (choice B), access to health care services (choice C), and access to transportation (choice D) are important factors in overall community health, they are not directly linked to preventing dermatitis in this scenario.