Nokea
The nurse must delegate some aspects of a homebound client's care to a home health aide. Which intervention should the nurse delegate to the home health aide?
- A. evaluating a pressure sore
- B. applying a prosthetic device
- C. performing a sterile dressing change
- D. assessing the client's need for an elevated toilet seat
Correct Answer: B
Rationale: The correct answer is B: applying a prosthetic device. Home health aides are trained and authorized to assist with the application and management of prosthetic devices for clients. Evaluating a pressure sore (choice A) requires clinical assessment and judgment typically performed by a licensed healthcare provider such as a nurse. Performing a sterile dressing change (choice C) involves aseptic technique and wound care skills that are usually performed by licensed healthcare professionals. Assessing the client's need for an elevated toilet seat (choice D) involves a level of assessment and decision-making that is beyond the scope of practice for a home health aide.
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A female adult walks into a local community health clinic and tells the nurse that she is homeless and cannot seem to find help. Which statement indicates to the nurse that a client is feeling separated from society and helpless?
- A. "I'm feeling really isolated from everyone and scared."
- B. "I feel like I cannot get enough food to live any longer."
- C. "I know that I will always be poor so what's the use of trying?"
- D. "People like me are never respected, no matter how well we do."
Correct Answer: A
Rationale: Choice A is the correct answer because the statement reflects a sense of isolation and helplessness, indicating a profound emotional and social disconnect. The client expresses feeling separated from others and scared, highlighting a deep emotional distress. Choices B, C, and D touch on different issues such as food insecurity, hopelessness about poverty, and lack of respect, but they do not specifically address the feelings of isolation and helplessness mentioned in the client's statement.
A male client leaves his job at a nearby restaurant and visits the health clinic where he is diagnosed with viral conjunctivitis. While receiving discharge instructions from the nurse, the client states that he is feeling much better and plans to return to work for the afternoon shift. How should the nurse respond?
- A. advise the client to wear a face mask around other people
- B. ask the client what type of work he does at the restaurant
- C. instruct the client to use dark glasses if lighting is bright
- D. explain that the client should stay home for the next few days
Correct Answer: D
Rationale: The correct answer is D: explain that the client should stay home for the next few days. Viral conjunctivitis is highly contagious, and the client should avoid close contact with others until it resolves. Returning to work while still contagious can lead to the spread of the infection to coworkers and customers. Choice A is incorrect because wearing a face mask may not provide sufficient protection against spreading the virus in a close work environment. Choice B is irrelevant to the situation as the focus should be on the client's health and preventing the spread of the infection. Choice C is also unrelated to the management of viral conjunctivitis and does not address the contagious nature of the condition.
A client who is taking clonidine (Catapres, Duraclon) reports drowsiness. Which additional assessment should the nurse make?
- A. How long has the client been taking the medication?
- B. Assess the client's dietary habits.
- C. Check for signs of infection.
- D. Evaluate the client's sleep pattern.
Correct Answer: A
Rationale: The correct answer is A. When a client reports drowsiness while taking clonidine, the nurse should assess how long the client has been taking the medication. Drowsiness is a common side effect that can occur in the early weeks of treatment with clonidine. By understanding the duration of medication use, the nurse can determine if the drowsiness is a temporary effect that may decrease over time. Choices B, C, and D are incorrect because assessing the client's dietary habits, checking for signs of infection, or evaluating the client's sleep pattern would not directly address the drowsiness associated with clonidine use.
The nurse is assisting with the triage of clients at a large community disaster and finds a man lying on the ground, who states that the blast threw him out of a second-story window. Which action should the nurse implement first?
- A. Logroll the client to his side and assess for back injuries
- B. Perform a complete neurological assessment
- C. Open the client's airway immediately
- D. Place the nurse's hands around the client's neck to stabilize
Correct Answer: C
Rationale: Opening the client's airway immediately is the priority in this scenario. Ensuring the airway is clear takes precedence over other actions as it is crucial for the client's breathing and oxygenation. Logrolling the client to assess for back injuries may worsen the condition if there are spinal injuries, so this should not be done as the first step. Performing a complete neurological assessment is important but not the immediate priority over ensuring the airway is clear. Placing the nurse's hands around the client's neck to stabilize is incorrect and could potentially harm the client, as neck stabilization should only be done if there is a suspected neck injury, which is not indicated in this case.
The healthcare provider is planning a health education session for new parents on infant care. Which topic should be prioritized?
- A. signs of infant dehydration
- B. proper diaper changing techniques
- C. immunization schedule
- D. breastfeeding positions
Correct Answer: A
Rationale: Recognizing signs of infant dehydration is crucial for ensuring the health and well-being of infants. Dehydration can be life-threatening for infants if not addressed promptly. Proper diaper changing techniques, while important for hygiene, can be learned incrementally. The immunization schedule and breastfeeding positions are also essential topics, but identifying signs of dehydration takes precedence as it requires immediate attention to prevent serious complications.