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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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The nurse is planning a health fair for high school students. Which assessment is most important for the nurse to obtain?
- A. Weight and height.
- B. Sexual activity.
- C. Immunization history.
- D. Visual acuity.
Correct Answer: B
Rationale: Assessing sexual activity is critical for high school students to address sexual health, STIs, and pregnancy risks, guiding tailored education and interventions.
A prescription for discharge is written for an elderly client who has asked to be discharged to home. The client lives alone and is able to walk 10 to 15 feet (3 to 4.5 meters) with assistance. Which action should the nurse implement first?
- A. Review the home medication schedule with the client and family.
- B. Provide the client with information about medical alert devices.
- C. Arrange for a bedside commode to be delivered to the home.
- D. Meet with the case manager to plan a home safety evaluation.
Correct Answer: D
Rationale: A home safety evaluation is critical to identify hazards and ensure the client's limited mobility is accommodated, preventing falls and ensuring safety.
A nurse designs a series of four weekly classes for clients with type 2 diabetes mellitus. Which information should the nurse use as an outcome evaluation for the classes?
- A. Fasting blood glucose average readings were 20% lower at the end of the classes.
- B. Discussion of food exchanges and calories was a well-attended class.
- C. Demonstrating the use of a blood glucose meter was an effective teaching strategy.
- D. Parking convenience for attendees continued to be a major concern.
Correct Answer: A
Rationale: Lower fasting blood glucose readings directly indicate improved diabetes management, reflecting the classes' effectiveness.
A migrant farm worker who lives in a mobile home with several other workers visits the Migrant Health Care Center. The client reports Increasing episodes of dizziness, headaches, abdominal cramps, and difficulty breathing. Which nursing action has the highest priority?
- A. Gather information about the client's recent exposure to pesticides.
- B. Obtain a blood sample to assess for possible lead paint exposure.
- C. Ask about the length of his workday and frequency of rest breaks.
- D. Determine the number and age of persons living in the mobile home.
Correct Answer: A
Rationale: Symptoms like dizziness and breathing difficulty suggest pesticide poisoning, a common risk for farm workers, requiring immediate investigation to guide treatment.
The city health department director asks the community health nurse to make a presentation describing the greatest health concern facing the city. How should the nurse begin to collect the data needed for this presentation?
- A. Review morbidity data for the city's population compiled by the Bureau of Vital Statistics.
- B. Conduct a random telephone survey to determine the public's perception about health problems.
- C. Call American Medical Association members to determine the most frequently treated diagnoses.
- D. Survey major hospitals in the area to determine the most common reasons for admissions.
Correct Answer: A
Rationale: Morbidity data from the Bureau of Vital Statistics provides comprehensive, objective information on disease prevalence, identifying major health concerns.