Nokea
A community health nurse is planning an educational program for a group of women who are postmenopausal. Which of the following outcomes is appropriate for this program?
- A. Clients will schedule bone density screening
- B. Clients will arrange for mammograms every 3 years
- C. Clients will start hormone replacement therapy
- D. Clients will significantly decrease caloric intake
Correct Answer: A
Rationale: The correct answer is A: Clients will schedule bone density screening. This outcome is appropriate because postmenopausal women are at increased risk for osteoporosis, making bone density screening crucial for early detection and prevention. It is a proactive measure to assess bone health and reduce the risk of fractures.
Explanation for why other choices are incorrect:
B: Clients will arrange for mammograms every 3 years - While mammograms are important for breast cancer screening, the focus of this program is on postmenopausal women's specific health needs related to bone health.
C: Clients will start hormone replacement therapy - Hormone replacement therapy has risks and benefits and should be individualized based on a woman's specific health history and needs. It is not a universal recommendation for all postmenopausal women.
D: Clients will significantly decrease caloric intake - Caloric intake is important for overall health, but the specific focus of this program is on bone health and screening, not weight management.
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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.
A school nurse is planning safety education for a group of adolescents. The nurse should give priority to which of the following topics as the leading cause of death for this age group?
- A. Sports injury prevention
- B. Motor vehicle safety
- C. Substance abuse prevention
- D. Gun safety
Correct Answer: B
Rationale: The correct answer is B: Motor vehicle safety. Adolescents are at a higher risk of motor vehicle accidents, making it the leading cause of death in this age group. This is due to factors like inexperience, risk-taking behaviors, and distractions while driving. Sports injury prevention (A) is important but not the leading cause of death. Substance abuse prevention (C) is significant but not the primary cause of death. Gun safety (D) is also crucial but not as prevalent as motor vehicle accidents.
A home health nurse is visiting a client who had a stroke 2 months ago. Which of the following findings should the nurse report to the interprofessional care team?
- A. The client dresses her affected side first.
- B. The client bears weight on their arms when using crutches.
- C. The client coughs when swallowing her medications.
- D. The client's caregiver fills a pill organizer weekly.
Correct Answer: C
Rationale: The correct answer is C: The client coughs when swallowing her medications. This finding should be reported because coughing when swallowing can indicate dysphagia, a common complication after a stroke that can lead to aspiration pneumonia. Aspiration pneumonia is a serious condition that requires immediate attention to prevent respiratory complications. Reporting this finding to the interprofessional care team allows for prompt assessment and intervention to prevent further complications.
Choices A, B, and D are not as urgent to report to the interprofessional care team. A client dressing their affected side first, bearing weight on arms with crutches, or a caregiver filling a pill organizer weekly do not pose immediate risks to the client's health and do not require immediate intervention from the care team. These findings are important for monitoring the client's progress and adjusting care plans but do not have the same level of urgency as coughing when swallowing medications.
A nurse is counseling a client who is to undergo enzyme-linked immunosorbent assay (ELISA) testing for HIV. Which of the following information should the nurse include?
- A. The test monitors progression of the disease
- B. The test measures antibodies to the virus
- C. The test results are accurate 24 hr after exposure to the virus
- D. A positive result requires initiating immunoglobulin administration
Correct Answer: B
Rationale: The correct answer is B because ELISA testing for HIV measures antibodies to the virus, indicating exposure to the virus. This is crucial for diagnosing HIV infection. Choice A is incorrect because ELISA does not monitor disease progression. Choice C is incorrect as it takes weeks, not hours, for accurate results post-exposure. Choice D is incorrect as immunoglobulin administration is not the treatment for a positive HIV result.
A nurse is working in a shelter following a disaster. Which of the following is the priority action for the nurse to take?
- A. Create diversionary activities for children
- B. Address the physical needs of clients
- C. Help clients gather needed supplies
- D. Explore feelings the clients are experiencing
Correct Answer: B
Rationale: The correct answer is B: Address the physical needs of clients. This is the priority action because in a disaster setting, ensuring the basic physical needs of clients such as food, water, shelter, and medical care takes precedence to ensure their survival and well-being. Without addressing these needs first, the clients' health and safety could be compromised. Creating diversionary activities for children (A), helping clients gather supplies (C), and exploring clients' feelings (D) are important but secondary to addressing immediate physical needs. It is crucial to prioritize basic survival needs before addressing emotional or social needs in a disaster situation.