Nokea
The parish nurse notes that an elderly male client has had a 5 lbs weight loss since his check-up one month ago. The client has good hygiene, still drives a car, and lives alone. To which agency should the nurse refer this client?
- A. the adult day care center
- B. the social security administration office
- C. the women, infants, and children office
- D. the senior citizen center
Correct Answer: D
Rationale: The correct answer is 'D: the senior citizen center.' In this scenario, the elderly male client is experiencing unexplained weight loss, which could be indicative of underlying health issues or social isolation. Referring him to the senior citizen center is appropriate as it can provide social support, resources, and programs tailored to address the client's weight loss and overall well-being. Choice A, the adult day care center, is not the most suitable option as the client is still independent and living alone. Choice B, the social security administration office, and Choice C, the women, infants, and children office, are not relevant in this context and do not address the client's specific needs related to weight loss and social support.
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When caring for a client with a tracheostomy, which action should the nurse take first when performing tracheostomy care?
- A. Remove the inner cannula.
- B. Clean the stoma with normal saline.
- C. Change the tracheostomy ties.
- D. Suction the tracheostomy.
Correct Answer: D
Rationale: Suctioning the tracheostomy is the priority action because it ensures a patent airway before proceeding with any other tracheostomy care interventions. This step helps clear secretions and maintain airway patency, which is crucial for the client's respiratory status. Removing the inner cannula, cleaning the stoma, or changing the tracheostomy ties can follow once the airway is clear. Therefore, options A, B, and C are secondary actions compared to suctioning the tracheostomy.
The healthcare provider is assessing the laboratory results for a client who is admitted with renal failure and osteodystrophy. Which findings are consistent with this client's clinical picture?
- A. Serum potassium of 4.0 mEq/L and total calcium of 9 mg/dL.
- B. White blood cell count of 15,000/mm3.
- C. Serum potassium of 5.5 mEq/L and total calcium of 6 mg/dL.
- D. Hemoglobin of 12 g/dL and phosphorus of 2 mg/dL.
Correct Answer: C
Rationale: In renal failure and osteodystrophy, there is an alteration in serum electrolyte balance. The correct answer is serum potassium of 5.5 mEq/L and total calcium of 6 mg/dL. Renal failure is associated with hyperkalemia (elevated serum potassium) and hypocalcemia (low total calcium levels). Hyperphosphatemia is also commonly seen in renal failure. Choice A is incorrect as it describes normal levels of serum potassium and total calcium. Choice B is unrelated to the client's condition. Choice D is incorrect as it does not reflect the typical electrolyte imbalances seen in renal failure and osteodystrophy.
The healthcare provider is assessing a client who has returned from surgery. Which finding requires immediate intervention?
- A. Heart rate of 90 beats per minute.
- B. Oxygen saturation of 92%.
- C. Temperature of 99°F (37.2°C).
- D. Pain at the surgical site.
Correct Answer: C
Rationale: A temperature of 99°F (37.2°C) in a postoperative client requires immediate intervention as it may indicate the presence of infection. Elevated temperature post-surgery can be a sign of surgical site infection or systemic infection, which can lead to serious complications if not addressed promptly. Monitoring and managing a fever in a postoperative client is crucial to prevent further complications. The other findings, such as a heart rate of 90 beats per minute, oxygen saturation of 92%, and pain at the surgical site, are common postoperative assessments that may not necessarily require immediate intervention unless they are significantly out of normal range or causing severe distress to the client.
The nurse is teaching a group of high school adolescents about safety associated with traumatic injuries. Which factor causing spinal cord injuries should the nurse discuss with the adolescents?
- A. motor vehicle accidents
- B. violent assault
- C. sports injuries
- D. falls
Correct Answer: A
Rationale: The correct answer is A: motor vehicle accidents. Motor vehicle accidents are a significant cause of spinal cord injuries among adolescents due to the high impact forces involved. While violent assault, sports injuries, and falls can also lead to spinal cord injuries, statistics show that motor vehicle accidents are a leading cause in this age group. Educating adolescents about the risks and preventive measures related to motor vehicle accidents is crucial in promoting their safety and well-being.
A community health nurse is conducting a needs assessment in a rural area. Which data source is most likely to provide comprehensive information about the community's health status?
- A. Focus groups with community members
- B. Local hospital admission records
- C. State health department reports
- D. Surveys conducted by healthcare providers
Correct Answer: C
Rationale: State health department reports are the most likely data source to provide comprehensive information about the community's health status. These reports offer a broad overview of health statistics and trends that can guide community health interventions. Focus groups with community members, although valuable for gathering qualitative insights, may not provide comprehensive health status data. Local hospital admission records are limited to specific healthcare utilization data and do not capture the overall health status of the entire community. Surveys conducted by healthcare providers may offer some insights but may not provide the breadth and depth of information available in state health department reports.