Nokea
The partner of an older adult client who has Alzheimer's disease reports that he is not eating. The client's partner refuses to assist the client with feeding and insists the client feed himself without help. What is the priority action the nurse should take?
- A. Arrange for Meals on Wheels assistance
- B. Determine the client's ability to self-feed
- C. Direct the home health aide to assist with meals
- D. Refer the client's partner to an Alzheimer's support group
Correct Answer: B
Rationale: The correct answer is B: Determine the client's ability to self-feed. This is the priority action because it addresses the immediate concern of the client not eating due to the partner's refusal to assist. By assessing the client's ability to self-feed, the nurse can identify any barriers or challenges the client may be facing, such as physical limitations or cognitive impairments. This assessment will guide the nurse in developing an appropriate plan of care to ensure the client's nutritional needs are met.
The other choices are incorrect because they do not directly address the client's current situation.
A: Meals on Wheels assistance may be helpful but does not address the immediate need for the client to eat.
C: Directing the home health aide to assist assumes the client is willing to accept help, which may not be the case.
D: Referring the client's partner to an Alzheimer's support group is important for long-term support but does not address the immediate issue of the client not eating.
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A newly hired occupational health nurse is assessing hazards in the work environment. Which of the following actions will help the nurse detect potential physical hazards?
- A. Survey workers about job-related emotional stress.
- B. Measure the noise levels at various locations in the facility.
- C. Identify industrial toxins that are present in the environment.
Correct Answer: B
Rationale: The correct answer is B: Measure the noise levels at various locations in the facility. This action will help the nurse detect potential physical hazards because excessive noise can lead to hearing damage and other health issues. By measuring noise levels, the nurse can identify areas where noise levels exceed safe limits and implement control measures.
Surveying workers about emotional stress (Choice A) is important for psychological well-being but does not directly address physical hazards. Identifying industrial toxins (Choice C) is important for chemical hazards, not physical hazards related to noise. The other choices are not provided, but measuring noise levels is the most relevant action for detecting physical hazards in this scenario.
A community health nurse is planning a program for adolescents about preventing STIs. Which of the following actions should the nurse take first?
- A. Collect data to identify barriers to learning
- B. Establish methods to evaluate program outcomes
- C. Obtain visual aids that feature adolescents
- D. Provide computer-based education
Correct Answer: A
Rationale: The correct answer is A: Collect data to identify barriers to learning. This should be the first step because understanding the specific challenges and obstacles that adolescents face in learning about preventing STIs is crucial for designing an effective program. By collecting data, the nurse can tailor the program to address the specific needs of the target audience, ensuring that the information is relevant and accessible.
Choice B, establishing methods to evaluate program outcomes, would come later in the program planning process after the content has been developed and implemented. Choice C, obtaining visual aids featuring adolescents, and choice D, providing computer-based education, are also important but should be considered after identifying barriers to learning to enhance the effectiveness of the program.
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.
A nurse case manager is providing discharge planning for a client. The nurse is functioning in which of the following roles when arranging for the delivery of medical equipment to the client's home?
- A. Consultant
- B. Systems allocator
- C. Coordinator
- D. Advocate
Correct Answer: C
Rationale: The correct answer is C: Coordinator. In this scenario, the nurse is functioning as a coordinator by arranging for the delivery of medical equipment to the client's home. As a coordinator, the nurse is organizing and facilitating the necessary resources and services to meet the client's needs. This role involves collaborating with various healthcare providers and agencies to ensure a smooth transition for the client post-discharge.
The other choices are incorrect because:
A: Consultant - This role involves providing expert advice or recommendations based on specialized knowledge. The nurse in the scenario is not simply providing advice but actively coordinating services.
B: Systems allocator - This role involves allocating resources within a healthcare system. While the nurse is arranging for resources, the focus is on the specific client's needs rather than broader system allocation.
D: Advocate - This role involves speaking up for the client's rights and needs. While advocacy may be a part of the nurse's role, in this scenario, the primary focus is on coordination of services.
A school nurse is teaching bicycle safety to a group of school-age children. Which of the following statements by a child indicates an understanding of the teaching?
- A. I should walk my bicycle through crosswalks.
- B. I should keep my bicycle far away from the curb.
- C. I should ride my bicycle side-by-side when biking with a friend.
- D. I should ride my bicycle in the opposite direction of the traffic flow.
Correct Answer: A
Rationale: The correct answer is A: "I should walk my bicycle through crosswalks." This statement indicates an understanding of the teaching because it shows awareness of pedestrian rules at crosswalks, emphasizing safety when not riding the bicycle. Walking the bicycle through crosswalks ensures visibility to drivers and prevents accidents.
Summary:
B: Keeping the bicycle far from the curb increases the risk of colliding with vehicles or obstacles.
C: Riding side-by-side is unsafe as it can obstruct traffic and increase the chances of accidents.
D: Riding in the opposite direction of traffic flow is dangerous and against traffic laws, increasing the risk of head-on collisions.