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The school nurse is assessing a group of middle school students for signs of scoliosis and discovers a student with a noticeable unequal symmetry of the upper and lower back. Which intervention is most important for the nurse to implement?
- A. Make a referral to have the scoliosis further evaluated.
- B. Measure the degree of the thoracic and lumbar curvature.
- C. Ask about the student's ability to participate in sports.
- D. Review students health record for a recent growth spurt.
Correct Answer: A
Rationale: Referring for further evaluation by a specialist ensures accurate diagnosis and timely management of potential scoliosis, addressing the observed asymmetry.
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While assessing a child at the community health clinic, the nurse notes that the toddler has multiple bruises on his legs and buttocks. After reporting suspected child abuse to the supervisor, which action should the nurse take next?
- A. Obtain a restraining order against the father.
- B. Encourage the mother to file a police report.
- C. Ask the child if his father ever spanks him.
- D. Refer the family to protective service agencies.
Correct Answer: D
Rationale: Referring to protective service agencies ensures a specialized investigation and intervention, prioritizing the child's safety and well-being.
A 66-year-old client is retiring and will no longer have health insurance through a place of employment. Which agency should the client be referred to by the employee health nurse for health insurance needs?
- A. Women, Infant, and Children program.
- B. Consolidated Omnibus Budget Reconciliation Act provisions.
- C. Medicare.
- D. Medicaid.
Correct Answer: C
Rationale: Medicare is the federal health insurance program for those 65 and older, making it the most suitable for a 66-year-old retiree's insurance needs.
A client who recently returned from international travel presents to the clinic with high fever, chills, headache, and muscular aches. The healthcare provider suspects severe acute respiratory syndrome (SARS). To prevent transmission of the virus to others, which instruction is most important for the nurse to provide?
- A. Wear a N95 respirator mask during direct contact with others.
- B. Cover mouth and turn head when coughing
- C. Use meticulous hand washing technique.
- D. Discard all tissues used during coughing in a biohazard bag.
Correct Answer: A
Rationale: An N95 respirator mask is critical for preventing airborne transmission of SARS, offering superior protection compared to other measures like hand washing or tissue disposal.
Which annual screening should the nurse include when planning an eye health program at a preschool?
- A. Glaucoma.
- B. Red light reflex.
- C. Visual acuity.
- D. Conjunctivitis.
Correct Answer: C
Rationale: Visual acuity screening is essential for preschoolers to detect vision issues like amblyopia or refractive errors that could impact development and learning, making it the priority for annual eye health programs.
The nurse is caring for a client with gonorrhea. The client reports having sex with multiple partners. Which response should the nurse provide?
- A. Emphasize that using safe sex practices removes the risk of sexually transmitted Infections (STIs)
- B. Clarify that all sexually transmitted infections (STIs) are transmitted through sexual intercourse.
- C. Discuss that partners without similar symptoms may not be infected.
- D. Instruct the client on the importance of notifying sexual partners.
Correct Answer: D
Rationale: Notifying sexual partners is critical to prevent further spread of gonorrhea, ensuring they are tested and treated, as asymptomatic individuals can still transmit the infection.