Community Health Assessment A and B

A school nurse is teaching health promotion to a group of staff members who sit at a desk and use a computer for 8 hr at a time. Which of the following information is the priority for the nurse to include?

"Point and flex your toes periodically." MY ANSWER The greatest risk to staff members who are immobile for long periods of time is a venous thromboembolism. Therefore, the nurse should encourage the staff members to frequently change the position of their feet and legs. Wrong "Take a walk after work." The nurse should encourage the staff members to exercise to reduce the risks associated with a sedentary lifestyle. However, another option is the priority. "Have your visual acuity assessed regularly." The nurse should encourage the staff members to have regular eye exams. However, another option is the priority. "Adjust your chair so that your elbows are at desk height." The nurse should encourage the staff members to sit in an ergonomically correct position to prevent injury. However, another option is the priority.

A nurse is developing an educational program about bioterrorism and smallpox. The nurse should include the teaching that the smallpox rash is expected to first appear in which of the following locations?

Face MY ANSWER The nurse should teach that the smallpox rash is expected to first appear on the face. Wrong Posterior shoulders The nurse should teach that the smallpox rash is expected to first appear on the face before spreading to areas such as the posterior shoulders. Abdomen The nurse should teach that the smallpox rash is expected to first appear on the face before spreading through the trunk, including the abdomen. Lower extremities The nurse should teach that the smallpox rash usually appears on the extremities last.

A nurse is assessing a new client. Which of the following information should the nurse include in the cultural portion of the assessment?

Food preferences MY ANSWER Food preferences are a part of cultural assessment. Wrong Employment status Employment status is not a part of cultural assessment. History of illnesses History of illnesses is not a part of cultural assessment. Sexual orientation Sexual orientation is not a part of cultural assessment.

A community health nurse is teaching a client who was newly diagnosed with active pulmonary tuberculosis about disease transmission. Which of the following should the nurse include?

Household members should take isoniazid for at least 6 months. The household members of a client who has active pulmonary tuberculosis are at risk for developing the disease. Therefore, taking isoniazid prophylactically for at least 6 months is recommended. Wrong Household members should be placed in respiratory isolation. Respiratory isolation is not necessary for the household members of a client who has active pulmonary tuberculosis. Wear a mask in the home. It is not necessary for a client who has active pulmonary tuberculosis to wear a mask in the home setting. Have a repeat Mantoux test in 3 months. MY ANSWER A client who has active pulmonary tuberculosis should receive a chest x-ray for future screenings.

A public health nurse is planning a community health promotion program for hypertension prevention. Which of the following interventions should the nurse include as a tertiary prevention strategy?

Implement an exercise program for clients who have hypertension. MY ANSWER The nurse should implement tertiary prevention strategies for clients who have hypertension to promote the highest level of functioning possible, which can include regular exercise to maintain an active lifestyle. Wrong Teach clients who have a family history of hypertension how to monitor blood pressure. The nurse should implement secondary prevention strategies for early detection and treatment for clients who are at risk for developing hypertension, which can include teaching clients who have a family history of hypertension to monitor their blood pressure. Conduct a hypertension screening clinic for the community. The nurse should implement secondary prevention strategies for early detection and treatment for clients who are at risk for developing hypertension, which can include conducting a hypertension screening clinic for the community. Provide education about risk factors for hypertension. The nurse should implement primary prevention strategies for a healthy population to prevent or delay hypertension, which can include providing community education about risk factors and early intervention.

A community health nurse is discussing the role of a faith community nurse with a chaplain. Which of the following information should the nurse include in the discussion?

The faith community nurse can facilitate substance abuse support groups. MY ANSWER This is one of the roles of a faith community nurse. Wrong The faith community nurse can provide pharmacological pain management for clients who have a terminal illness. This is the role of a home health or hospice nurse. The faith community nurse can plan workplace safety training for employees in a local factory. This is the role of an occupational health nurse. The faith community nurse can provide wound care for clients in their homes. This is the role of a home health or wound care nurse.

A community health nurse is working to meet the health care needs of residents in a rural community. Which of the following characteristics should the nurse identify as a barrier to health care resources for this population?

Unavailability of outreach services Lack of availability of outreach services is a barrier to health care for residents in rural areas. Wrong Lack of cohesiveness among community members Rural residents often rely on community networks for support. Therefore, the nurse should not expect to encounter a lack of cohesiveness among this population. Disinterest by members of the population in providing input for community health programs MY ANSWER Residents of rural communities are no less likely to be interested in health promotion than members of urban communities. Less autonomy in providing client care Health care providers have greater independence and work more autonomously in providing client care in rural areas.

A community health nurse is conducting a chart review of a group of individuals who were each perpetrators of partner violence. Which of the following findings should the nurse identify as a risk factor for becoming a perpetrator?

Witnessing family violence MY ANSWER The nurse should identify a history of witnessing or experiencing family violence as a risk factor for becoming a perpetrator of partner violence. Other risk factors include poor coping skills, inability to assume adult roles, lack of problem-solving ability, and inadequate social skills. Wrong Frequent social interaction with friends The nurse should identify that perpetrators of partner violence are often distrustful of others. High self-esteem The nurse should identify that perpetrators of partner violence often express feelings of worthlessness. Submissive The nurse should identify that perpetrators of partner violence often exhibit a dominant personality.

A community health nurse is teaching a client who is overweight about steps to take to begin an exercise program. The nurse should identify that which of the following statements is an indication that the client understands the teaching?

"I will see my doctor before beginning an exercise program." MY ANSWER The client should see their provider before beginning an exercise program. The client should receive a complete physical exam and obtain approval for exercise. Wrong "I will need to purchase exercise equipment before I can start." Walking, jogging, lifting half-gallon jugs filled with sand, or doing sit-ups and push-ups are all types of exercise that do not require special equipment. I should try to perform aerobic exercise for an hour a day, 5 days a week." When beginning a new exercise program, the client should aim to perform aerobic exercise three to five times a week or every other day for about 30 min. "I should avoid participating in weight-lifting exercises." The client should balance a routine of strength training exercises with aerobic activities. Performing different types of exercise can help the client increase activity tolerance

A home health nurse is evaluating a caregiver's technique for providing cadre to a client who has a chronic tracheostomy. Which of the following statements by the caregiver indicates an understanding of the procedure?

"I will use tap water to clean the inner cannula." The caregiver can use tap water when performing tracheostomy care. Wrong "I should remove the soiled ties before replacing them with clean ones." The caregiver should leave the old ties in place until the new ones are secured to prevent accidental displacement of the tracheostomy tube. "I should use a slip knot to secure the tracheostomy ties." MY ANSWER The caregiver should use a square knot when securing the ties to avoid accidental displacement of the tracheostomy tube. "I will cut a four inch by four inch gauze to use as a dressing." The caregiver should fold the 4 inch x 4 inch (10 cm x 10 cm) gauze dressing before placing it at the tracheostomy site. Cutting the gauze can result in fine fibers being aspirated.

A nurse is planning to teach a community group about the meningococcal vaccine. The nurse should identify that which of the following clients should receive the vaccine?

A client who is moving into a college dormitory Individuals living in crowded areas, such as dormitories, should receive the meningococcal vaccine. Wrong A client who is traveling to northern Europe MY ANSWER Individuals traveling to northern Europe are not at an increased risk for meningococcal meningitis. An infant who has bronchiolitis The meningococcal vaccine is not recommended for an infant who has bronchiolitis. An infant who is 4 weeks old The minimum age for immunization with the meningococcal vaccine is 8 weeks.

A public health nurse is participating in a disaster preparedness planning committee for a local community that is at risk for hurricanes. Which of the following information should the nurse contribute to the plan?

A list of areas within the community where residents speak multiple languages The public health nurse, who is most familiar with the community, should contribute this information to the disaster plan to assist in aiding and evacuating residents who are at high-risk. Wrong A list of residents who have experienced a hurricane in the past and will not need evacuation The nurse should include a plan to assist in evacuating all residents. Prior experience with hurricane survival does not indicate that the residents are prepared to withstand a new disaster. How to activate the local medical facilities' emergency-management plans MY ANSWER The Joint Commission mandates that all medical facilities have a response plan that includes the actions that facility staff can take in the event of a local disaster. The community plan can include notifying the facility, but the staff within the facility must activate this plan. The name of the individual who is necessary to implement the plan A disaster plan requires readiness regardless of who is present at the time of the disaster.

A hospice nurse is teaching about expected grief reactions with the family of a client who has end-stage pancreatic cancer. Which of the following information should the nurse include?

"A component of healthy grieving is the ability to openly express your anger." MY ANSWER The nurse should teach the family that they will experience feelings of anger, guilt, shame, and doubt while grieving. The ability to openly express their feelings of anger is an expected grief reaction. wrong "It is common to experience a persistent state of sadness while grieving." The nurse should teach the family that they should expect emotions to fluctuate frequently while grieving. A persistent state of sadness is an indication of clinical depression. "Disturbances in your self-esteem is an expected grief reaction." The nurse should teach the family that their self-esteem is not altered while grieving. Disturbances in self-esteem is an indication of clinical depression. "You will feel a sense of hopelessness throughout the grieving process." The nurse should teach the family that they should continue experiencing feelings of hope while grieving. A sense of hopelessness is an indication of clinical depression.

A home health nurse is visiting an older client and notes that unwashed dishes are piled up and news papers cover the front steps. Which of the following questions should the nurse as the client to determine if the client is socially isolated?

"How often do you have visitors come to see you?" MY ANSWER The nurse should ask this question because it addresses the issue of social isolation by determining the frequency of contact between the client and others. Wrong Why haven't you brought in your newspapers?" This question does not determine the frequency of contact between the client and others. "Do you need help completing your housework?" This question does not determine the frequency of contact between the client and others. "Have you considered moving to an assisted living facility?" This question does not determine the frequency of contact between the client and others.

The nurse manager at a community health clinic is presenting an in-service for nurses about assessing clients who have experienced violence. Which of the following statements by a nurse indicates an understanding of the teaching?

"I should determine whether a client who has been sexually assaulted requires a rape kit examination." MY ANSWER Clients who report sexual assault within a certain time frame should undergo a rape kit examination. In some cases, collection must be obtained within 24 hr of the occurrence. However, the time frame can vary based on the type of assault. The nurse should also provide information regarding support groups and resources for clients who were sexually assaulted. Wrong "I do not need to ask about violence at future visits once I determine that a client is not at risk." The nurse should assess clients for violence at every visit because the risk for violence can change. "I should not document the name of the person the client accuses of the violence in the client's medical record." The nurse should document the name of the person the client accuses of the violence in the medical record for future reference in a possible legal case. "I should wait until I see signs of physical violence before I help the client develop a safety plan." Developing a safety plan is a priority for a client who is a recipient of violence regardless of the type, such as physical, psychological, or sexual. The nurse should provide the client with information about resources that can help, such as shelters and support groups.

A nurse is preparing an educational program about influenza for a group of community health nurses. Which of the following activities should the nurse include as an example of tertiary prevention?

Administer antiviral medications within 48 hr to clients who have manifestations of influenza. MY ANSWER Tertiary prevention involves ways to reduce the complications of illness, which includes administering antiviral medications to clients who already have influenza. Wrong Offer classes to elementary school teachers about handwashing. Primary prevention involves ways to prevent the occurrence of disease, which includes frequent handwashing. Provide information to occupational nurses about the reasons for employees to not come to work. Secondary prevention involves ways to prevent the spread of an existing infection, which includes isolating individuals who have manifestations of illness. Provide immunizations at long-term care facilities. Primary prevention involves ways to prevent the occurrence of illness, which includes providing immunizations to susceptible populations.

A school nurse is conducting visual acuity testing for a school-aged child using a Snellen letter chart. Which of the following actions should the nurse take?

Allow the child to keep her glasses on during the testing. MY ANSWER When using the Snellen letter chart to assess a school-age child's visual acuity, the nurse should allow the child to keep her glasses on during the test. Wrong Have the child stand 5 feet away from the Snellen letter chart. When using the Snellen letter chart to assess a school-age child's visual acuity, the child should stand or sit at least 10 feet away from the chart. The chart should be placed at the child's eye level. Progress to the next line once the child reads two symbols correctly. When using the Snellen letter chart to assess a school-age child's visual acuity, the child should progress to the next line once she is able to read at least four symbols on the current line. Begin the test by instructing the child to use both eyes to read the chart. When using the Snellen letter chart to assess a school-age child's visual acuity, the nurse should instruct the child to cover the right eye first, and then move to the left eye. The final step is to have the child read the chart using both eyes.

A nurse is giving a presentation about family violence at a local community center. Which of the following information should the nurse include?

Child maltreatment is more common in homes where partner violence is present. MY ANSWER Child maltreatment is very common in homes where partner violence is present. Wrong Socially active parents and guardians are at greater risk for becoming violent. Parents and guardians that isolate themselves from friends, neighbors, and family are more prone towards violence. Partner violence occurs more frequently in lower socioeconomic households. Studies show that there is no connection between socioeconomic level and partner violence. Child maltreatment is linked to family financial strain. Children who are abused are less likely to become abusers. Studies show that children who are abused are more likely to become abusers.

A community health nurse suspects an outbreak of scabies in the local area. Which of the following actions should the nurse take first?

Determine the incidence rate. MY ANSWER The first action the nurse should take when using the nursing process is to perform an assessment. The nurse should determine the number of new cases of scabies in the community for comparison to prior incidence data in order to monitor for an increase. Wrong Educate the community about disease transmission. While it is important to educate the community about disease transmission to prevent further cases, this is not the first action the nurse should take. Institute prophylactic treatment.While it is important to institute prophylactic treatment to prevent infestation, this is not the first action the nurse should take. Discuss treatment plans with the clients' families. While it is important to discuss treatment plans with the clients' families to promote adherence to treatment, this is not the first action the nurse should take.

A community health nurse is conducting a program regarding crime reduction strategies for older adult clients at the senior center. Which of the following statements indicates an understanding of the information

I should remove the identification tag that is on my key ring." MY ANSWER The nurse should inform the clients to remove any identification tag on their key ring. If keys are lost along with identifying information, then the client is left vulnerable to home invasions. Wrong "I should store my purchases in the back seat when I am out shopping." The nurse should inform the clients to lock all purchases and bags securely in the trunk where they are not visible to others. "When I open my front door, I will ask for identification if the person is someone I do not know." The nurse should inform the clients to use an optical viewer and not to open the door automatically. The door should not be opened for a stranger, and the client should not reveal they are home alone. "When I am in my car, I will keep my personal items on the seat beside me." The nurse should inform the clients to keep personal items, such as a purse, on the floor rather than the seat. Having them out of sight makes them harder for someone to grab.

A nurse is assessing a new client at a public health clinic. Which of the following areas should the nurse address as part of cultural assessment?

Illness practices MY ANSWER A cultural assessment focuses on beliefs, values, meanings, and behavior of people within a client's cultural, ethnic, or religious group. This includes culturally-based practices that relate to health and illness. Wrong A client's immunization status is not part of a cultural assessment. A client's immunization status is not part of a cultural assessment. Food allergies Allergies are a result of a particular client's hypersensitivity to a substance, not of cultural beliefs or practices.

A community health nurse is conducting a needs assessment of a community. The nurse should identify that which of the following methods will yield direct data?

Informant interviews The nurse should identify that informant interviews with community members or leaders will provide direct data. This information can help the nurse identify services needed by the community. Wrong Health surveys MY ANSWER Health surveys will yield secondary data. Medical records Medical records will yield secondary data. Medical records Medical records will yield secondary data.

A nurse is caring for a client who has a positive gonorrhea culture. Which of the following actions should the nurse take?

Instruct the client that recent sexual partners will need to be treated. MY ANSWER The nurse should instruct the client that sexual partners from the past 60 days should be referred for evaluation and treatment of gonorrhea. Wrong Instruct the client to return for a blood test in 1 month. Gonorrhea is detected through the collection of vaginal, cervical, or urine specimens. There is no indication for a blood test. Blood tests are used to detect HIV and syphilis. Administer penicillin G 2.4 million units IM once. The nurse should administer penicillin G for a client who has syphilis. Teach the client how to apply imiquimod 5% cream to the lesions. Topical imiquimod 5% cream is used for the treatment of human papillomavirus.

A home health nurse is reviewing several client request regarding complementary strategies. The nurse should identify that which of the following alternative therapies is contraindicated for a client?

Kava for a client who has cirrhosis MY ANSWER Although kava has been used to promote sleep, it can cause severe liver damage, which can lead to the need for a liver transplant. Using kava could worsen the condition of a client who has cirrhosis. Therefore, the nurse should plan to discuss safer alternatives with the client. Wrong Acupressure therapy for a client who has back pain Acupressure can be safely used by clients who have back pain to promote comfort. Other methods to promote comfort include massage and therapeutic touch. Hippotherapy for a school-age child who has cerebral palsy Hippotherapy, or horse riding, has proven to be helpful for children who have cerebral palsy. Other methods helpful for children who have cerebral palsy include color-light therapy and pet therapy. Valerian for a client who has anxiety and insomnia Although valerian has not been proven to be effective in relieving insomnia, this situation does not indicate a safety concern.

A home health nurse is caring for a client who has breast cancer. Which of the following assessment should the nurse identify as an indication that the client is coping effectively?

Makes eye contact MY ANSWER The nurse should recognize that making eye contact is an indication of effective coping. Wrong Exhibits anhedonia Anhedonia, the reduced ability to experience pleasure in everyday life, is an indication of ineffective coping. Sleeps 14 hr each day Excessive sleeping is an indication of ineffective coping. Laughs inappropriately Laughing inappropriately is an indication of ineffective coping.

A public health nurse is monitoring medication compliance for a group of migrant workers who are being treated for TB. The nurse should use information from which of the following resources to assist with this process?

Migrant Clinicians Network (MCN) Migrant workers frequently change locations and move from job to job. This can interfere with the client adhering to the 6 to 12 month TB treatment plan. The MCN is a tracking program developed so that health care providers can access prior provider information and maintain TB treatment continuity for these clients. Wrong Agency for Healthcare Quality and Research (AHRQ)The AHRQ provides evidence-based clinical guidelines for client care, such as pain management, cancer screening, and diabetes mellitus treatment Centers for Disease Control and Prevention (CDC) MY ANSWER The CDC provides information about STIs and immunization guidelines. U. S. Preventive Services Task Force (USPSTF) The USPSTF is an organization that reviews preventative services and suggests appropriate services for primary medical care and topics for research.

A school nurse is serving on a community disaster planning committee looking at school shooter scenarios. Which of the following actions should the nurse plan to take during the response phase?

Perform triage and provide hands-on care as needed to victims. MY ANSWER During the response phase of disaster planning, the school nurse's role can include triage, providing hands-on care, coordinating the first-aid response team, and serving as a counselor to those in need. Wrong Conduct ongoing assessments to identify potential hazards. Performing assessments and identifying potential hazards is the role of the school nurse during the prevention phase of disaster planning. Provide disaster training to school personnel. Providing disaster training to school personnel is the role of the school nurse during the preparedness phase of disaster planning. Serve as a liaison between available community resources and those in need. Serving as a liaison between resources and those in need is the role of the school nurse during the recovery phase of disaster planning.

A clinic nurse is instructing a 65-year-old client about immunizations. Which of the following should the nurse recommend that the client receive during this visit/

Pneumococcal vaccine MY ANSWER The nurse should instruct the client to receive an annual influenza vaccine and a pneumococcal vaccine at age 65 and every 10 years thereafter. Wrong Rotavirus vaccine The rotavirus vaccine series should be completed by the age of 8 months. Meningococcal conjugate vaccine The meningococcal conjugate vaccine should be received at 11 or 12 years of age with a booster dose at 16 years of age. Human papillomavirus vaccine The human papillomavirus vaccine series, which includes two immunizations 6 months apart, should begin at 11 or 12 years of age.

A community health nurse is working with a community where the incidence of violence has increased. Which of the following actions should the nurse take as a tertiary prevention strategy?

Provide victims of violence with referral information to crisis lines. MY ANSWER Referring victims of violence to available community resources is a tertiary prevention strategy. The community health nurse should be aware of all available community resources. Wrong Provide open education sessions to teach parenting skills. Providing open education sessions to teach parenting skills is a primary prevention strategy that can assist in preventing new episodes of child maltreatment. Identify potential community risk factors for violence. Identifying community risk factors for violence is a primary prevention strategy. Identifying influential factors, such as high unemployment levels, lack of neighborhood support systems, and lack of community cohesiveness, can assist the nurse with developing ways to intervene before further violence occurs. Assess for evidence of violence during routine encounters. The nurse can assess for evidence of violence, such as unexplained injuries, depression, or malnourishment, during community encounters with individuals. This secondary strategy can assist the nurse to intervene and prevent further violence.

A nurse is collecting demographic data as a part of a community assessment. Which of the following should the nurse include?

Racial distribution Racial distribution is part of demographic data. Other types of demographic data include marital information, population density, and death and birth rates. Wrong Family genograms MY ANSWER Family genograms are not part of demographic data. Genograms are used as part of a family assessment. Number of open water sources Although it is something important to consider in a community assessment, the number of open water sources is not considered demographic data. Presence of condemned buildings Although it is something important to consider in a community assessment, the presence of condemned buildings is not considered demographic data.

A community health nurse is planning an educational program for farmers about occupational health risk. Which of the following risks should the nurse include?

Respiratory disorders MY ANSWER Farmers are at an increased risk for respiratory disorders due to exposure to agricultural chemicals, such as herbicides and pesticides. Other health risks for farmers include accidents with vehicles and machinery, dermatitis, dental problems, and stress and anxiety disorders. Wrong Cardiomyopathy Cardiomyopathy is not an occupational health risk for farmers. Diabetes mellitus Diabetes mellitus is not an occupational health risk for farmers. Hypertension Hypertension is not an occupational health risk for farmers.

A school nurse is conducting a vision screening for a school-age child who wears eyeglasses. Which fo the following actions should the nurse take when using the Snellen eye chart?

Screening each participant using a geriatric depression scale The nurse should not plan to include screening using a geriatric depression scale as a primary prevention activity. Depression screenings are a secondary prevention activity. Wrong Dim the lights in the testing room.The nurse should ensure that there is good lighting for the chart without any glare. Ask the child to remove her eyeglasses prior to the test. The nurse should first test the child with her eyeglasses. The nurse should not test the child without her eyeglasses first and then with them because this will cause the child to strain as she reviews the chart. Position the child 7.6 m (25 feet) from the chart. The nurse should measure and position the child 3 to 6.1 m (10 to 20 feet) from the chart, depending on the specific chart used.

A nurse is preparing a community education program about health care needs during pregnancy. The nurse should include that which of the following vaccines is safe to administer to a client who is pregnant?

Tetanus, diphtheria, pertussis (Tdap) The nurse should include that a client who is pregnant should receive the Tdap vaccine between 27 and 36 weeks of gestation. Wrong MY ANSWER The herpes zoster vaccine is contraindicated during pregnancy. The varicella vaccine is contraindicated during pregnancy. Measles, mumps, and rubella The measles, mumps, and rubella vaccine is contraindicated during pregnancy.

A case manager at a home health agency is obtaining equipment for a client's home use. Which of the following actions is a violation of client confidentiality?

The case manager left a clipboard with the client's prescription information face up on the office desk. MY ANSWER When using a clipboard, the case manager should place the clipboard on the desk face down so that a client's personal health information is not visible to other individuals. Wrong The case manager used a computer at the agency with an automatic sign-off mechanism. The automatic sign-off is a safety mechanism that helps to safeguard client information. The computer will automatically sign off a user's account after a predetermined length of time so personal health information is not left visible to the public. The case manager sent a fax to the equipment company on a machine using programmed speed dial. Fax machines with programmed speed dial keys can help eliminate a misdial, preventing the misdirecting of personal health information to the wrong location. The case manager shared the client's name with the equipment company. The case manager can share the client's name with the equipment company because they will be a part of this client's health care team. Only those who will have direct involvement in the client's care can have access to a client's personal health information.

Community leaders have requested a meeting with a community health nurse to discuss creating a mobile meals program. Which of the following information should the community health nurse assess first?

The need for the program MY ANSWER When using the nursing process, the nurse should first assess the need for the mobile meals program. This action allows the nurse to collect data on the client, which is the community, and meets the first step of program planning. The needs of the community will determine all other steps of the planning process. Wrong The leadership support of the community While the support afforded by the leaders of the community should be determined prior to implementing the program, it is not the first thing the nurse should assess. The accessibility of residences While the accessibility of residences will need to be determined prior to implementing the program, it is not the first thing the nurse should assess. The availability of volunteers While the availability of volunteers will need to be determined prior to implementing the program, it is not the first thing the nurse should assess.

A nurse on the scene following a mass casualty explosion is triaging a client who has a large, open occipital wound and the following findings: respiratory rate 6/min, agonal pattern; capillary refill time 4.5 seconds; nonresponsive to painful stimuli. Which of the following actions should the nurse take?

Turn the client to left semi-Fowler's position and begin assessing the next client. MY ANSWER Principles of triage indicate that clients who have extensive injuries and a low-probability of survival do not receive treatment. Therefore, the nurse should provide only comfort measures before moving on to assess the next client. Wrong Place a firm pressure dressing to the occiput and open the airway. The nurse should not perform this action for the client because it does not meet prioritization guidelines following a mass casualty incident. Apply a cervical spine collar and perform a focused neurological exam. The nurse should not perform this action for the client because it does not meet prioritization guidelines following a mass casualty incident. Request that the client be assessed immediately by the next available provider. The nurse should not perform this action for the client because it does not meet prioritization guidelines following a mass casualty incident.

A hospice nurse is caring for client who is at the end of life and has developed dyspnea and noisy breathing. Which of the following actions should the nurse take?

Use a fan in the client's room. A fan moves the air, which stimulates the client's trigeminal nerve and can minimize the sensation of dyspnea. Wrong Suction the client's oropharynx. Suctioning is uncomfortable and distressing for a client and is not effective for a client who is at the end of life. Administer the client's pain medication intramuscularly. The nurse should not administer the client's pain medication intramuscularly because of decreased circulation, which results in poor absorption of the medication. Place the client in Trendelenburg position. MY ANSWER The nurse should position the client with the head of the bed elevated. This increases chest expansion and decreases dyspnea.

A school nurse is conducting hearing screening procedures in an elementary school. Which of the following instructions should the nurse provide when performing the Rinne test?

"After I place this tuning fork behind your ear, tell me when you no longer hear the sound." MY ANSWER This is the appropriate instruction for a Rinne test, a hearing evaluation that compares air conduction and bone conduction of sound. Wrong "After I place the tuning fork on your scalp, tell me if you hear the sound better in one ear or the same in both ears." This instruction is for a Weber test, a test that evaluates lateralization of sound. "Use your finger to close one ear while I whisper some numbers into your other ear." This instruction is for a whispered voice test, an initial screening to determine the need for further testing of a client's hearing. "You'll wear headphones and press the button when you hear a sound." This instruction is for audiometry, which provides a precise measurement of hearing ability. A client wears earphones or headphones and gives a specific signal, such as pressing a button or raising a finger, to indicate when tones of various intensities are heard.

A community health nurse is assessing a group of clients for risk factors of violent behavior. Which of the following findings should the nurse identify as a risk factor for developing violent behavior?

A client says they were spanked as a child. MY ANSWER Clients who have prior exposure to violence have a greater potential for continuing the violent and abusive behavior. Wrong A client reports getting a new job. Having employment and social support protects the client against developing violent behavior. A client has a history of participating in volunteer activities. Having a history of participating in volunteer activities allows the client to interact with others and have support outside the home. This protects the client against developing violent behavior. A client lives in the rural community where they grew up. Crowded living conditions or social isolation are risk factors for developing violent behavior. However, living in a rural community is not considered a risk factor.

A nurse in a community health clinic is preparing to administer an immunization to a 5 y/o child. Which of the following actions should the nurse take?

Ask the child to pretend to blow up a balloon during the injection. MY ANSWER The nurse should ask the child to pretend to blow up a balloon during the injection. This serves as a distraction for the child, which decreases pain perception. Wrong Reassure the child that the injection is not going to hurt. The nurse should explain to the child that the injection might feel like a sting or a poke for a short time. The nurse should then provide a distraction for the child during the injections. Ask the child's parent to leave the room during the injection. The child likely has anxiety and fear about receiving an injection and the presence of a parent can decrease this fear. The parent can talk to and reassure the child during the injection. Request that the child count backwards from the number 10 during the injection. A 5-year-old child does not have the cognitive development to perform this task. The nurse should have the child use a distraction during the injection, such as blowing bubbles or looking at a book.

A nurse is preparing to administer medication to client who has active TB. Which of the following precautionary measures should the nurse take?

MY ANSWER A client who has active tuberculosis requires airborne precautions to prevent the spread of droplet nuclei smaller than 5 microns. The nurse should wear an N95 respirator when administering medication to prevent transmission of the infection. Wrong The nurse should use disposable equipment when administering medication to a client who has an infection that requires contact precautions, such as shigellosis, herpes simplex, or scabies. The nurse should wear protective eyewear when performing a procedure that might cause a splash or splatter, such as wound irrigation. Wear gloves. The nurse should wear gloves when administering medication to a client who has an infection that requires contact precautions, such as shigellosis, herpes simplex, or scabies.

A case manager is planning an educational program fro a client who had DM. Which of the following activities should the nurse include when using the psychomotor domain of learning?

Observe the client's technique for drawing up insulin. MY ANSWER The nurse should include this activity in order to use the psychomotor domain of learning because it requires coordination and the use of motor skills. Wrong Review a color diagram of the food pyramid with the client. The nurse should include this activity in order to use the cognitive domain of learning because it involves the client understanding and applying information. Show the client a video about how to monitor blood glucose levels. The nurse should include this activity in order to use the cognitive domain of learning because it includes learning new information and applying it in a different way. Encourage the client to discuss their feelings of self-worth. The nurse should include this activity in order to use the affective domain of learning because it deals with the expression of feelings and the development of attitudes, beliefs, and values.

A public health nurse is lobbying Congress funding for health screenings provided to migrant farm workers. Which of the following concepts is the nurse demonstrating?

MY ANSWER This is an example of advocacy. Advocacy is supporting or seeking a specific course of action for the benefit and on behalf of a person, group, or community. Wrong Principlism Principlism is the dominant approach to ethical decision making and is comprised of the principles of respect for autonomy, nonmaleficence, beneficence, and distributive justice. Deontology is an ethical theory based on the idea that actions must be based on moral rules or duty, regardless of the consequences. Communitarianism is the idea that an individual's rights and needs should be balanced with social responsibility. This includes the idea that individuals are shaped by the cultural values of their community and do not live in isolation.

A nurse is caring for a client who has stage IV pancreatic cancer and has received information regarding available treatment option. Which of the following is the responsibility of the nurse if the client chooses to forgo treatment and enter hospice care?

Make the hospice referral in accordance with the client's decision. MY ANSWER The nurse should follow the ethical principle of respect for client autonomy and make the hospice referral for the client. Wrong Verify that the client's health insurance pays for hospice services. The nurse's responsibility does not include verifying the insurance coverage of hospice services. Recommend a second opinion from another provider. Providing advice is nontherapeutic and is not congruent with the principle of respect for client autonomy. Assess whether or not the family agrees with the client's decision. This action is a breach of client confidentiality and is not congruent with the principle of respect for client autonomy.

A school nurse is reviewing the records of four students who are returning to school after being diagnosed with MRSA. Which of the following actions should the nurse take?

Provide education about MRSA throughout the school system. MY ANSWER The nurse should provide education about hand hygiene and self-care to help prevent the spread of MRSA throughout the school and community. Wrong Report the cases of MRSA to child protective services. A diagnosis of MRSA is not an indicator of child maltreatment. Recommend prophylactic treatment for classmates. A prophylactic treatment is not available for MRSA. Coordinate an immunization clinic at the school. An immunization is not available to reduce the spread of MRSA.

A nurse in a clinic is caring for a client who reports taking ginkgo bilobas for several weeks after seeing a neuropathic healer. The nurse should instruct the client that ginkgo biloba can alter the effects of which of the following medications?

Warfarin Ginkgo biloba can hinder coagulation. Therefore, the nurse should instruct the client that ginkgo biloba can alter the effects of warfarin. Wrong Metoprolol Ginkgo biloba does not alter the effects of metoprolol. Digoxin MY ANSWER Ginkgo biloba does not alter the effects of digoxin. Diltiazem Ginkgo biloba does not alter the effects of diltiazem.

A nurse in a rural health clinic is caring for a client who has heart failure. The client states, I'm not going to take any more heart medicine." Which of the following responses should the nurse make?

"Can you tell me more about your decision to stop taking your medicine?" MY ANSWER The nurse is asking an open-ended question, which encourages continued communication and allows the nurse to investigate the reasons why the client has decided to stop taking the medicine. Wrong "Why did you decide to stop your heart medicine?" The nurse is asking a "why" question, which can sound accusatory and make the client defensive. "I think you should speak with your provider before you stop taking your medication."The nurse is giving advice about the client's decision, which implies that the nurse knows what is best for the client. "I understand your feelings, but you should trust your provider." The nurse is showing disapproval of the client's decision, which can make the client defensive and discourage continued communication.

A nurse is teaching a client who has a new diagnosis of hepatitis A about how to prevent the spread of the virus. Which of the following instructions should the nurse include?

"Clean your bathroom fixtures with a chlorine bleach solution." MY ANSWER The client should clean bathroom fixtures with a 10:1 chlorine bleach solution. The hepatitis A virus spreads via feces and survives on human hands since it is resistant to soap and detergents. Wrong "Double-bag tissues used for coughing or blowing the nose." Hepatitis A is spread by oral-fecal contamination or by consuming contaminated food or water. Therefore, there is no indication to double-bag tissues used for coughing or blowing the nose. "Use shared hand towels to dry your hands after washing." The client should not share bath or hand towels with other members of the household. The hepatitis A virus spreads via feces and survives on human hands since it is resistant to soap and detergents. "Use barrier contraceptives during sexual contact for 2 weeks after beginning treatment." The client should avoid sexual contact until the provider confirms that the hepatitis A antibody test is negative. If the client engages in sexual contact after the hepatitis A test is negative, barrier contraception should be used.

A nurse manage in a community health clinic is teaching a group of nurses about client rights and informed consent of the following statements should the manager include?

"Clients can revoke their informed consent even after signing the form." MY ANSWER The nurse manager should explain to the group of nurses that the right of consent also includes the right to refuse. Therefore, clients maintain the right to cancel the procedure and revoke consent at any time, even after signing the form. Wrong "Clients can designate their partner to witness the signing of the informed consent form." A client must receive information about the procedure from the provider, who will disclose the benefits and risks of the treatment or procedure and answer any questions the client might have. A nurse then witnesses the signing of the form, confirming that the client appears competent to give consent. Therefore, clients cannot designate their partner to witness the signing of the consent form. "Clients can select an advance directives status on the consent form." A client's advance directives are not a part of informed consent. Therefore, the nurse should include the status of the advance directives in a client's medical record. "Clients must give verbal consent prior to receiving life-saving interventions." In an emergency situation, clients might not be able to verbalize consent. The provider should try to obtain consent from someone legally authorized to give consent if the client is unconscious. If that is not possible, life-saving interventions are still performed under the assumption the client would want treatment.

A nurse is performing a home visit for a client who has TB. As the nurse is leaving the client's house, a neighbor asks, "Is it true that my neighbor has TB?" Which of the following responses should the nurse make?

"Do you have questions about tuberculosis?" This response addresses the neighbor's concerns while protecting the client's confidentiality. Wrong "You should ask the public health department." This statement leads the neighbor to believe that the information is obtainable. However, the public health department will not disclose this information. "Have you ever been tested for tuberculosis?" MY ANSWER This response does not address the neighbor's concerns and might contribute to further anxiety about contracting TB. You should take precautions against this infection." This response violates the client's confidentiality by indicating that the neighbor's suspicions are correct.

A home health nurse is caring for a client who is immunocompromised due to chemotherapy. Which of the following statements should the nurse make regarding food safety?

"Frozen food should be cooked immediately after it is thawed." MY ANSWER The nurse should inform the client that frozen food should be thawed in a bowl in the refrigerator and should be cooked as soon as it is thawed. Wrong "Beef is the only meat that is acceptable to eat with a pink center." The nurse should inform the client that all meat and poultry should be cooked until there is no pink coloring in the center "Keep the inside of your refrigerator at 47 degrees Fahrenheit or below." The nurse should inform the client that, for safe food storage in the home, the inside of the refrigerator should be kept at 40° F or below. "Eat any leftovers within one week of preparation." The nurse should inform the client to eat leftovers within 3 to 4 days.

An adult child who is terminally ill and at the end of life approaches a hospice nurse and asks "What can I do to help relieve my father's pain?" Which of the following interventions should the nurse suggest?

"Give your father brief hand massages." MY ANSWER Soft and brief hand massages can reduce pain and stress in palliative care settings. Wrong "Increase the illumination in your father's room." Dimming the environmental light has a calming effect and can reduce pain and anxiety. "Avoid using analgesics unless your father exhibits nonverbal signs of pain." The nurse should suggest administering analgesics on an ongoing basis to promote comfort, even if the client does not appear to be uncomfortable. "Administer citalopram when your father is agitated." The nurse should suggest nonpharmacological comfort measures that have pain-relieving benefits. The client's provider can also prescribe analgesics to relieve the client's pain. Citalopram is an antidepressant that is not effective for acute pain.

A hospice nurse is admitting a client who has cancer and is no longer receiving treatment. The client tells the nurse, "I don't understand why all of this has happened to me." Which of the following responses should the nurse make?

"How do you feel about stopping your treatments?" MY ANSWER This response by the nurse is therapeutic because it encourages the client to evaluate and discuss his perspective and feelings about stopping treatments. Wrong "Everyone feels this way when first entering hospice care." This response by the nurse is nontherapeutic because it minimizes the client's feelings, which can result in the client feeling belittled or insignificant. "Why didn't you enter hospice care sooner?" This response by the nurse is nontherapeutic because it can cause the client to become defensive or feel he is being judged. "I think you made the right decision by foregoing treatment." This response by the nurse is nontherapeutic because it can cause the client to continue hospice care to please others instead of feeling he can continue treatment if desired.

A public health nurse is providing information to a client who has alcohol use disorder and its asking about treatment. Which of the following statements should the nurse identify as as indication that the client understands the information?

"I can expect to get help with other aspects of my life while in treatment." MY ANSWER Successful treatment of alcohol use disorder is more likely if the client receives help in other areas of their life, such as their physical health, psychological well-being, and family interactions. Wrong "I am not eligible for an outpatient program until I have completed an inpatient program first." There is no requirement for a client to complete an inpatient program before entering an outpatient program. There are outpatient programs available, but clients should have a strong support system to facilitate success. "Once I make it through detoxification, I will be free of my addiction." The nurse should inform the client that medical detoxification to manage the acute physical withdrawal manifestations is the first step in treating alcohol use disorder. There is no cure for alcohol use disorder and the client must have a commitment to life-long sobriety. "I will not have to completely stop drinking alcohol if I go into an inpatient treatment program." Treatment for alcohol use disorder requires complete abstinence.

A public health nurse is conducting an educational session about Lyme disease for a group of older adult clients at a senior center. Which of the following statements should the nurse identify as an indication the the clients understand the teaching?

"I can take penicillin for 10 to 14 days to manage Lyme disease." A client who receives a diagnosis of Lyme disease in the early stages should respond to 10 to 14 days of penicillin or tetracycline therapy. Wrong "I should get an annual immunization to prevent Lyme disease." Currently, there is no immunization to prevent Lyme disease. An older adult client should get an annual influenza immunization. "I can get Lyme disease from a mosquito bite."The nurse should instruct the clients that the mode of transmission for Lyme disease is from the bite of an infective ixodid tick. "I will have abdominal pain and diarrhea if I get Lyme disease." MY ANSWER A client who has Lyme disease can have a lesion from a tick bite with mild influenza-like manifestations, such as fever, fatigue, and malaise. A client who has Escherichia coli is more likely to have abdominal pain and diarrhea.

A nurse at a county health clinic is caring for a client who has recently assumed the role of primary caregiver for their parent. Which of the following statements by the client indicates that she is experiencing role conflict?

"I feel overwhelmed with not having enough time for my mom as well as my children." MY ANSWER Role conflict occurs when a client performs two or more roles that are in opposition of each other. Caring for children and a parent can cause feelings of stress for the client and lead to conflict within the family. Wrong "I hope my siblings will be able to visit and help care for mom for a few days." The client is exploring potential ways in which their siblings might be able to relieve the role of caregiver temporarily. This statement might be an indication that the client is experiencing role strain. "I am glad that my job is flexible, so I can accommodate my mom's needs." The client is identifying a positive aspect of how the role as an employee fits with the role as a caregiver. By assimilating the caregiver role with other responsibilities, the client has enhanced their self-esteem and ability to perform various roles successfully. "I don't think my partner likes having to help more with the household chores." This statement indicates that the client and their partner might be experiencing difficulties assimilating the role as a caregiver with the client's partnership. This might be an indication that the client and their partner are experiencing role ambiguity.

A community health nurse is conducting a vision screening at a health fair for an older adult client who has age related macular degeneration. Which of the following statements should the nurse identify as an indication that the client is adapting to the changes?

"I have a prescription bottle magnifier to help me read my pill bottle labels." MY ANSWER The client can obtain a prescription bottle magnifier, or other low-vision optical devices, to assist with reading the labels on prescriptions, which helps the client to remain independent. Wrong "I canceled all of my magazine subscriptions since I can't read them." The client should obtain large print magazines and other reading materials that have large, dark, and evenly-spaced printing. "I purchased green towels to use in my bathroom." The client should obtain brightly colored towels with primary colors at the upper end of the spectrum, such as red and orange, because these are easier for a client who has age-related macular degeneration to see. "I have learned that I cannot to go outside when the sun is bright." The client should obtain sunglasses that have yellow or amber lenses because they will decrease the glare and allow the client to go outside even when the sun is bright.

A nurse in a community health clinic is providing home safety teaching to the guardian of a 2 month old infant. Which of the following statements by the guardian indicates an understanding of the nurse instructions

"I should offer my baby a pacifier at bedtime and when he takes naps during the day." MY ANSWER The nurse should instruct the guardian to offer the infant a pacifier for napping and at bedtime because this practice has been shown to decrease the risk for sudden infant death syndrome (SIDS). The nurse should instruct the guardian to place the infant supine for sleep and to avoid reinserting the pacifier if it falls out when the infant falls asleep. Wrong "I should place my baby's head on a pillow when he is napping on the couch." The nurse should instruct the guardian to avoid allowing the infant to nap or sleep on the sofa because this increases the risk for injury to the infant. The nurse should also instruct the guardian to avoid the use of pillows, toys, bumper pads, quilts, or comforters in the infant's crib. These items increase the risk for suffocation and sudden infant death syndrome (SIDS). "I should scrub my hands briskly for 10 seconds after changing my baby's diaper." The nurse should instruct the guardian to scrub their hands vigorously for a minimum of 20 seconds after changing the infant's diaper, using the toilet, coughing, sneezing, or when preparing food. This practice prevents the spread of acute illness to the infant. "I should keep my home thermostat set between 75 and 80 degrees Fahrenheit." The nurse should instruct the guardian to maintain a home temperature between 20° to 22.2° C (68° to 72° F) to prevent overheating the infant.

A nurse is providing education regarding lead exposure to a group of clients who live in a housing development built in 1968. Which of the following client statements indicates an understanding of the teaching?

"I will increase the amount of red meat and milk in my child's diet." Children should receive adequate amounts of iron and calcium in their diets to prevent lead absorption from their environment. Wrong The client should use cold tap water to prepare infant formula because hot water dissolves lead more quickly from the pipe than cold water. "I will vacuum our wood floors every week." The client should wet mop wood floors to prevent aerosolizing lead particles. "I will use a dry-sanding technique when preparing to repaint my front door." MY ANSWER The client should use a wet-sanding technique to prevent aerosolizing lead particles.

A home health nurse is evaluating a partner's understanding of postoperative care for a client who had a total hip arthroplasty. Which of the following statements by the partner indicates an understanding of the prescribed care?

"I will remind my partner to use a walker when moving around in the house." The client should use a walker when ambulating. The walker provides stability and support for the client, decreasing the risk for falls. Wrong "I will place a heating pad at the incision site to help manage pain." The client's partner should place an ice pack on the client's incision site to control pain and reduce swelling. "I will inspect the incision site every other day." MY ANSWER The client's partner should inspect the client's incision site every day for manifestations of redness, heat, or drainage. "I will let my partner skip exercises on days when the pain is increased." The client should reduce the number of repetitions for prescribed exercises when pain is increased. However, it is important to exercise on both "good" and "bad" days, regardless of pain level. Pain medication can be administered 30 min to 1 hr prior to exercises.

A nurse is caring for a client who has terminal lung cancer and is receiving hospice care. Which of the following statements should the nurse identify as an indication that the client is in the denial stage of the grief process?

"I'm looking forward to my daughter's wedding next year." During the denial stage of the grief process, the client rejects the reality of the impending loss. Wrong "I don't deserve to die. This just isn't fair." During the anger stage of the grief process, the client exhibits increased anxiety and might project anger toward themselves and others. "If I could just make it through this, I'd never smoke again." MY ANSWER During the bargaining stage of the grief process, the client tries to find a way to avoid loss or impending death through bartering. "I'm going to plan my memorial service next week." During the acceptance stage of the grief process, the client establishes coping strategies and accepts the impending loss.

A community health nurse is talking with a client who recently experience the loss of a child following a long illness. The nurse should recognize that which of the following statements made by the client indicates a potential for suicide?

"Nothing feels good to me and I know it never will." MY ANSWER The nurse should recognize that this is a covert statement an individual might say if they are contemplating suicide. The client's statement reflects a sense of hopelessness, which is a manifestation of depression and a risk factor for suicide. "I am at a loss for words. I cry all the time." This statement is an expected expression of grief for a client who recently experienced the loss of a child. This is part of the disequilibrium stage of Bowlby's stages of grief. "I do not know why God took my baby." This statement is a normal expression of grief for a client who recently experienced the loss of a child. This is part of the anger stage of Kübler-Ross's stages of grief. "It just does not seem possible." This statement is a normal expression of grief for a client who recently experienced the loss of a child. This is part of the denial stage of Kübler-Ross's stages of grief.

A community health nurse is discussing palliative care with the family of a client who has stage II ovarian cancer and is receiving chemotherapy. Which of the following statements should the nurse make regarding palliative care?

"Palliative care will help your family member live as actively as possible." MY ANSWER The nurse should tell the family that the intention of palliative care is to support the client's comfort and quality of life so the client is able to remain active until death. Wrong "Palliative care is intended to prolong the life of your family member." The nurse should tell the family that the purpose of palliative care is not to hasten or delay the death of the client. "Palliative care can't begin until your family member stops curative treatments." The nurse should tell the family that palliative care can be used along with curative treatments, such as chemotherapy. "Palliative care is limited to addressing the medical needs of your family member." The nurse should tell the family that palliative care focuses on the relief of physical manifestations as well as spiritual, emotional, and psychosocial needs of the client.

A public health nurse is developing a presentation for local day care providers about infectious childhood diseases. Which of the following statements should the nurse include?

"Respiratory syncytial virus is spread through contact with respiratory secretions from an infected person." The nurse should include this statement in the presentation because respiratory syncytial virus (RSV) is spread by direct contact with respiratory secretions while within 3 feet of a person who is infected. Manifestations of RSV include dyspnea, tachypnea, coughing, and wheezing. Wrong "Rotavirus infections in children peak during the summer months." MY ANSWER Rotavirus infections in children peak during the winter months of the year. Manifestations of rotavirus include fever and vomiting followed by watery diarrhea. "Children who have fifth disease will exhibit bloody diarrhea." Diarrhea is not an expected manifestation of fifth disease, also called erythema infectiosum. Clinical manifestations include a rash that gives the client a slapped-face appearance that progresses from the face down to the body. Other manifestations include fever, myalgia, nausea, vomiting, and lethargy. "Antiviral medications shorten the duration of a shigella infection." Antibiotics shorten the length of a shigella infection and decrease mortality rates. Manifestations of shigella include fever and anorexia followed by watery or bloody diarrhea.

A palliative care nurse is teaching a client who has cancer about the services that are available for the client. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

"This type of care can help me with pain control." Clients who have cancer might require complicated treatments that can cause pain, disfigurement, and emotional and psychological distress. Palliative care provides support and management of the disease process regardless of the prognosis, including pain management. Wrong "If I begin palliative care, I will have to stop my chemotherapy." A client who is experiencing an illness, such as cancer, can still receive palliative care even if the client is undergoing treatment for the disease. "I can begin palliative care when I have less than 6 months to live." MY ANSWER Clients who have a life-limiting and progressive illness, such as cancer, can receive long-term palliative care. Once the prognosis is short-term, the client can receive hospice care. "My family will not be involved with this type of care program." The nurse should instruct the client that palliative care provides support to all members of the client's family and support system.

A nurse is conducting a health promotion presentation to a group of older adult female clients between the ages of 65 and 75 years. Which of the following statements should the nurse include in the teaching?

"You should have your cholesterol checked every 3 years." The nurse should instruct the clients to have a total cholesterol and high-density lipoprotein check every 3 to 5 years until age 75. Wrong "You should have a colonoscopy every 5 years." The nurse should instruct the clients to have a colonoscopy every 10 years unless otherwise instructed by their provider. "You should have your vision checked every 3 years." MY ANSWER The nurse should instruct the clients to have their vision assessed annually. "You should have a mammogram every 5 years." The nurse should instruct the clients to have a mammogram every 1 to 2 years.

A school nurse is screening a group of children for potential child maltreatment. Which of the following situations should the nurse report to the provider?

A 5-year-old child who does not have a coat in the winter and is wearing a short-sleeved shirt MY ANSWER The nurse should recognize that a preschooler or a school-age child who is dressed inappropriately for the weather, unclean, or displays poor personal hygiene is exhibiting manifestations of potential child neglect and should be reported to the provider. Wrong A 6-year-old child who is wearing mismatched clothing The nurse should recognize that a 6-year-old child likes independence and might insist on wearing certain clothing that does not match. This is not a manifestation of potential child maltreatment. A 5-year-old child who has several bruises on his shins and reports he fell while playing The nurse should recognize that preschoolers and school-age children can fall during physical activity and exercise, resulting in bruises on their shins. This is not a manifestation of potential child maltreatment. A 6-year-old child who has a broken right arm that is casted and reports she fell from a bike The nurse should recognize that school-age children can fall off of a bike and break an arm. This is not a manifestation of potential child maltreatment. However, multiple new or old fractures at various stages of healing or a spiral fracture are manifestations of potential child maltreatment.

A community health nurse is working in a mobile health care clinic. Which of the following clients should the nurse assess first?

A client who has a new onset of confusion and slurred speech MY ANSWER When using the urgent vs. nonurgent approach to client care, the nurse should determine that acute changes in mental status and speech might indicate the client is experiencing a neurological problem that requires immediate intervention. Therefore, the nurse should assess this client first. Wrong A client who has COPD and an oxygen saturation of 90%A client who has COPD and an oxygen saturation of 90% is nonurgent because this is an expected finding for a client who has a chronic lung disease. Therefore, there is another client that the nurse should assess first. A client who has a temperature of 38.3° C (101° F) Although a temperature of 38.3° C (101° F) is above the expected reference range, it is a nonurgent finding. Therefore, there is another client that the nurse should assess first. A superficial partial-thickness burn is nonurgent. Therefore, there is another client that the nurse should assess first.

A nurse in an emergency department is triaging clients following an explosion at a local factory. Which of the following clients should the nurse identify as the priority/

A client who has tracheal deviation and shortness of breath A client who has tracheal deviation and shortness of breath most likely has a pneumothorax and requires immediate intervention for survival. Therefore, when using the survival approach to client care, the nurse should give priority to this client. Wrong A client who has superficial burns to 10% of the abdomen A client who has superficial burns to 10% of the abdomen does not have an immediate threat to life and can wait for treatment. Therefore, the nurse should not identify this client as the priority. A client who has agonal respirations and an open head injury MY ANSWER A client who has agonal respirations and an open head injury has a minimal chance of survival, even with intervention. Therefore, the nurse should not identify this client as the priority. A client who has a fracture of the humerus and a bleeding foot laceration A client who has a fracture of the humerus and a bleeding foot laceration does not have an immediate threat to life and can wait for treatment. Therefore, the nurse should not identify this client as the priority.

A school nurse is creating a plan of care for an adolescent client who has asthma and is experiencing physical education class. Which of the following interventions should the nurse include?

Administer a bronchodilator to the adolescent prior to class. MY ANSWER The nurse should administer a bronchodilator to the adolescent prior to class to improve oxygenation and prevent bronchospasm. The nurse can administer a total of three doses every 30 min following class if the adolescent is wheezing. Wrong Apply non-humidified oxygen via nasal cannula at 10 L/min to the adolescent 30 min prior to class. Oxygen should be administered to treat an acute asthma exacerbation and should be humidified to prevent drying of the airway passages, which can make breathings more difficult. Administering the oxygen 30 min prior to class will not prevent wheezing or bronchoconstriction during or after class. Ask the client's guardian to schedule a pulmonary function test (PFT) for the adolescent. A PFT is used to measure the lungs' resistance to flow, action, or change. The test uses spirometry to determine ventilation ability or the degree of airway obstruction and should be performed when the adolescent is not wheezing or experiencing other acute manifestations of asthma, such as breathlessness, coughing, and tightness in the chest. Instruct the adolescent to use a fluticasone inhaler every 15 min when wheezing begins during class. Fluticasone is an inhaled corticosteroid that reduces inflammation in the airways and is taken on a regular schedule to prevent acute asthma attacks. The school nurse should realize that fluticasone will not decrease the adolescent's bronchoconstriction once it begins.

A community health nurse has been contacted regarding a client diagnosis of influenza type A in an adult day care. Which of the following actions should the nurse take to assist in the prevention of an outbreak?

Administer antiviral medication to clients at the facility. Antiviral medications are administered to individuals who have been exposed to influenza type A to provide immediate protection and to help prevent an outbreak. Wrong Schedule immunizations for clients at the facility. MY ANSWER Immunizations do not provide immediate protection and, therefore, will not be effective in preventing an outbreak. The efficacy of the vaccine is also dependent on the strain of influenza used to produce it. Recommend that the day care center close for 2 weeks. A single client diagnosis of influenza does not warrant closing the facility. Quarantine and isolation are indicated for pandemic influenza. Give immune globulin to clients at the facility who have early manifestations of influenza. Immune globulin does not prevent or treat influenza and, therefore, will not be effective in preventing an outbreak.

A public health nurse is planning care for four clients. Which of the following interventions should the nurse recognize as tertiary prevention

Administering antibiotics to a client who has AIDS and was diagnosed with Pneumocystis jirovecii MY ANSWER Administering antibiotics to a client who has AIDS and was diagnosed with Pneumocystis jirovecii is an example of tertiary prevention. Wrong Participating in partner notification for a client who has an STI Participating in partner notification for a client who has an STI is an example of secondary prevention. Performing a serological screening for HIV for a client who is pregnant Performing a serological screening for HIV for a client who is pregnant is an example of secondary prevention. Providing chemoprophylaxis for malaria to a client who is traveling to mosquito-infested countries Providing chemoprophylaxis for malaria to a client who is traveling to mosquito-infested countries is an example of primary prevention.

A nurse is performing a community assessment and discovers the need for interventions to address tertiary mental health issues. Which of the following interventions should the nurse implement?

Advocate for funding to support local rehabilitation services. The nurse should advocate for funding to support local rehabilitation services as a tertiary prevention intervention. This action assists with limiting disability and providing treatment for clients who already have a diagnosed mental health disorder. Wrong Assess clients who live in a long-term care facility for depression. Assessing clients who live in a long-term care facility is a secondary prevention intervention. The focus is on screening for a mental health disorder so that early treatment can begin. Provide information about eating disorders to adolescents. Providing information about eating disorders to adolescents is a primary prevention intervention. The goal is to prevent the occurrence of a mental health disorder. Reinforce stress reduction techniques during a skills class with new parents and guardians. MY ANSWER Reinforcing stress reduction techniques during a skills class with new parents and guardians is a primary prevention intervention. The goal is to promote mental health and improve family functioning.

A nurse identifies an epidemic of influenza at a local assisted living facility. The nurse should identify which of the following as an environmental factor when using the epidemiological triangle to reduce disease transmission?

Cohorting of clients who test positive for influenza The nurse should identify that cohorting of clients who test positive for influenza is an environmental factor because it is an external influence on disease transmission. Wrong Infectivity of the influenza virus The nurse should identify the infectivity of the influenza virus as an agent factor because infectivity refers to the ability of the agent to enter and multiply within a client. Immunization of clients with the influenza vaccine MY ANSWER The nurse should identify that immunization of clients with the influenza vaccine is a host factor because immunity affects the ability of the host to resist the agent. Susceptibility of individual clients to the influenza virus The nurse should identify that susceptibility of individual clients to the influenza virus is a host factor because the current health status of the individual influences disease transmission.

A public health nurse is developing a visual health program by using a community-oriented approach. Which of the following interventions should the nurse include?

Consult with the local school nurse to schedule yearly vision screenings for students. MY ANSWER Consulting with the local school nurse to schedule yearly vision screenings for students focuses on the health care of a population rather than illness care for individuals. Therefore, this intervention is using a community-oriented approach. Wrong Develop a plan of care for a client who was newly diagnosed with glaucoma. Developing a plan of care for a client who was newly diagnosed with glaucoma focuses on illness care for individuals. Therefore, this intervention is using a community-based approach. Provide genetic counseling to the family of a newborn who has congenital cataracts. Providing genetic counseling to the family of a newborn who has congenital cataracts focuses on illness care for families. Therefore, this intervention is using a community-based approach. Teach a client who has vision loss about safety in the home environment. Teaching a client who has vision loss about safety in the home environment focuses on illness care for individuals. Therefore, this intervention is using a community-based approach.

A school nurse is discussing levels of prevention with a teacher. Which of the following activities should the nurse identify as a primary prevention strategy?

Demonstrate proper handwashing techniques. MY ANSWER This is an example of primary prevention, the goal of which is to promote health and prevent diseases from developing. Wrong Conduct vision and hearing screening for kindergarten enrollment. This is an example of secondary prevention, the goal of which is to detect and treat a condition in its early stages, often before manifestations become apparent. Report suspected child neglect to the proper authorities.This is an example of secondary prevention, the goal of which is to detect and treat a condition in its early stages, often before manifestations become apparent. Provide nutritional counseling for students who have diabetes. This is an example of tertiary prevention, which begins once a disease becomes apparent and includes attempts to limit the progression of the disease and subsequent disability.

A case manager is developing a discharge plan for a client who has a spinal cord injury and is in a rehabilitation facility. Which of the following actions should the nurse take first?

Determine the client's ability to perform self-care. MY ANSWER The first action the nurse should take when using the nursing process is to assess the client's needs. Determining a client's needs is the first step of the case management process which allows the case manager to plan client-centered care. Wrong Hold a care conference with the client to discuss treatment options. The nurse should hold a conference with the client to discuss treatment options as part of the diagnosis step of the nursing process. However, there is another action the nurse should take first. Contact service providers to determine the availability of services offered. The nurse should contact service providers to determine the availability of services for the client as part of the implementation step of the nursing process. However, there is another action the nurse should take first. Evaluate the client's satisfaction with the case manager's services. The nurse should determine if the client is satisfied with the services received as part of the evaluation step of the nursing process. However, there is another action the nurse should take first.

A community health nurse is providing care to a client who has stopped taking their prescribed b/p medication. Which of the following actions should the nurse take first?

Determine the client's reason for discontinuing the medication. MY ANSWER When using the nursing process, the first step the nurse should take is to assess the client. By determining the client's reason for discontinuing the medication, the nurse can promote adherence to treatment. Wrong Advise the client that adherence to the medication regimen will promote healthy outcomes. During the implementation phase of the nursing process, the nurse should advise the client that adherence to the medication regimen will promote healthy outcomes. However, another action is the priority. During the implementation phase of the nursing process, the nurse should discuss the consequences of discontinuing the medication with the client. However, another action is the priority. Educate the client about the benefits of the medication. During the implementation phase of the nursing process, the nurse should educate the client about the benefits of the medication. However, another action is the priority.

A community health nurse is planning to develop a community health program. Which of the following actions should the nurse take first>

Determine the need. MY ANSWER When using the nursing process, the first step the nurse should take is to assess or determine the need for a community program. Wrong Obtain resources. Obtaining needed resources to develop the community program occurs during the detailing phase of the planning process. During this phase, resources, costs, and specific program activities are determined. However, it is not the first action the nurse should take. Develop a budget. Developing a budget is a part of the overall evaluation of the plan. Selection of the plan is based on the availability of funding, benefits, and applicability for the community. However, it is not the first action the nurse should take. Review the literature. After identifying a need, the nurse should conduct a review of the literature to identify similar project plans. This review improves the overall quality and effectiveness of the health program by incorporating evidence-based practices. However, it is not the first action the nurse should take.

A community health nurse identifies an increase in the occurrence of osteoporosis-related fracture in female clients who are experiencing menopause. Which of the following primary prevention strategies should the nurse implement?

Encourage the clients to participate in weight-bearing activities. MY ANSWER Weight-bearing exercises, such as weight lifting, walking, and running, have been found to be beneficial in preventing osteoporosis. Wrong Advise the clients to avoid live-virus vaccines. There is no need for these clients to avoid live-virus vaccines. The nurse can caution the clients that certain medications, such as corticosteroids, increase the risk for osteoporosis. Educate the clients about the importance of avoiding sun exposure. Sun exposure with appropriate precautions is encouraged to increase the exposure to and absorption of vitamin D. Vitamin D is a necessary factor in the absorption of calcium, which helps prevent osteoporosis. Instruct at-risk clients to increase their intake of foods high in vitamin E. Vitamin E has no relationship to bone density and the prevention of osteoporosis. Clients should increase their dietary intake of calcium and vitamin D.

A community health nurse is creating an educational program for a group of older adults about mental health issues. Which of the following information should the nurse plan to include in the program?

Encouraging farmworkers to limit the amount of time spent using vibrating equipment Limiting the time spent using vibrating equipment will affect the environment for the farmworkers. The leadership style and rules of managers are also considered environmental factors. Wrong Encouraging farmworkers to limit the amount of time spent using vibrating equipment Limiting the time spent using vibrating equipment will affect the environment for the farmworkers. The leadership style and rules of managers are also considered environmental factors. Older adults are at increased risk for developing personality disorders due to isolation. Older adults can maintain strong relationships with family and friends, which provide socialization and support. Isolation is not a risk factor for nor does it lead to personality disorders in clients, regardless of age. Older adults are expected to experience depressive disorder due to increased age. Depressive disorder is not an expected part of the aging process. Older adults can experience life changes that could contribute to manifestations of depressive disorder. However, the rate of depression among older adults is approximately 50% of the rate of depression among younger adults.

A community health nurse is participating in a quality improvement plan for a local health department. Which of the following techniques should the nurse use for process evaluation of the facility>

Focus groups is correct. The nurse should include focus groups, which are small groups of individuals who use the health department services, for process evaluation of the facility. This information allows for review of the facility's strengths and weaknesses in the quality of client care delivery. Written audits is correct. The nurse should include written audits, which are written evaluations of the quality of care provided by the health department, for process evaluation of the facility. This information allows for review of the facility's strengths and weaknesses in the quality of client care delivery. Satisfaction survey is correct. The nurse should include satisfaction surveys, which are assessments of clients' perception of their care made via telephone or written questionnaires, for process evaluation of the facility. Interviews is correct. The nurse should include interviews of clients who use the health department's services for process evaluation of the facility. Wrong Values self-study is incorrect. A values self-study is performed as the first step in quality assurance when the health department determines the needs of the community, the services to offer, and develops a philosophy and overall objectives for the facility

A community health nurse is planning a presentation for adults who have a family history of Alzheimer's disease. Which of the following behaviors should the nurse include as an early manifestation of Alzheimer's disease?

Forgetting the location of common objects MY ANSWER Forgetting the location of common objects is an early manifestation of Alzheimer's disease. Wrong Withdrawal from social activities Withdrawal from social activities is a later manifestation of Alzheimer's disease. Experiencing incontinence Incontinence is a later manifestation of Alzheimer's disease. Neglecting personal hygiene Neglecting personal hygiene is a later manifestation of Alzheimer's disease.

A community health nurse is teaching a group of clients about environmental health hazards. Which of the following examples should the nurse include as a possible source of carbon monoxide exposure?

Gas ranges MY ANSWER Carbon monoxide is an odorless, colorless, tasteless gas that is emitted into the air. Gas ranges, motor vehicles, and fire places are potential sources for carbon monoxide exposure. Wrong Washing machines Washing machines are not a source of carbon monoxide exposure. Air conditioners Air conditioners are not a source of carbon monoxide exposure. Electric space heaters Electric space heaters are not a source of carbon monoxide exposure.

An occupational health nurse is assessing a client who reports taking ibuprofen daily. The nurse should counsel the client about the risk for which of the following adverse effect?

Gastric ulcerations MY ANSWER Daily use of NSAIDs, such as ibuprofen, increases the risk for gastric ulceration, perforation, and hemorrhage. Wrong Hypokalemia Hyperkalemia is an adverse effect of ibuprofen. Polycythemia Polycythemia is not an adverse effect of ibuprofen. Urinary retention Oliguria, dysuria, and hematuria are adverse effects of ibuprofen.

A community health nurse is caring for an adolescent who is seeking help for an unplanned pregnancy. Which of the following actions should the nurse take first?

Help the client obtain a provider for prenatal care. The client is an adolescent and experiencing an unplanned pregnancy, which are factors that place the client and fetus at risk for complications. Therefore, when using the safety/risk reduction approach to client care, the first action the nurse should take is to assist the client in obtaining prenatal care. Wrong Recommend that the adolescent meet with the school guidance counselor to discuss educational options. MY ANSWER The nurse should encourage the client to meet with the school guidance counselor regarding educational plans. However, another action is the priority. Educate the client about contraceptives to prevent future unplanned pregnancies. The nurse should provide education about family planning during the third trimester of pregnancy. However, another action is the priority. Provide information on parenting classes so the client can learn about caring for a newborn. The nurse should provide information about parenting classes to the client. However, another action is the priority.

A community health nurse is planning to establish a community garden to introduce new nutrition options in the area. Which of the following actions should the nurse take first to initiate the plan?

Identify community members who demonstrate an interest in the project. The first action the nurse should take when using the nursing process is to assess the community. By identifying those community members who demonstrate an interest in the project, the nurse can establish a local support group who will assist in engaging other community residents with establishing the garden. Wrong Hold a community information session to inform the residents of the plan. MY ANSWER The nurse should hold a community information session to inform the residents of the plan. This will encourage dialogue amongst the residents and enlist the help of others. However, there is another action the nurse should take first. Select residents to take on leadership roles in the project. The nurse should select residents to take on leadership roles in the project so the community can take ownership of the project, letting the nurse relinquish that control. However, there is another action the nurse should take first. Monitor the progress of the project to keep the project on course. The nurse should monitor the progress of the project to keep the project on course and to assist the residents in making changes and adjustments as necessary. However, there is another action the nurse should take first.

A nurse is working to improve health outcomes for people who are homeless. Which of the following actions should the nurse take first?

Identify the availability of local resources to assist people who are homeless. The first action the nurse should take when using the nursing process is to identify the availability of local resources to assist people who are homeless. By identifying resources already available, the nurse can prevent duplication of services and focus on the development of programs that are needed. Wrong Develop a free program that screens for high-risk health concerns. MY ANSWER The nurse should develop a reduced-fee or free program that screens for high-risk health concerns to assist with early diagnosis and intervention for health problems that affect people who are homeless. However, there is another action the nurse should take first. Work with local leaders to ensure people who are homeless have access to a food bank. The nurse should work with local leaders to ensure people who are homeless have access to a food bank to improve nutrition and ensure that basic needs are being met. However, there is another action the nurse should take first. Advocate for a local multiservice center that is centrally located. The nurse should advocate for a local multiservice center that is centrally located to provide needed care for people who are homeless in a single location that is accessible. However, there is another action the nurse should take first.

A public health nurse is planning an educational program for a group of nurse at a community health department about pertussis infection. Which of the following information should the nurse include?

Individuals transmit the pertussis bacteria through airborne droplets. Transmission occurs when an individual who has an infection with Bordetella pertussis coughs. Wrong Individuals who have had pertussis do not require immunization. Individuals who have a history of infection with Bordetella pertussis do not maintain permanent immunity against reinfection and should still receive the vaccine. Newborns should receive the first dose of the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine prior to discharge from the hospital. MY ANSWER Infants receive an immunization against diphtheria, tetanus, and pertussis in the form of the DTaP vaccine. Infants should receive the first dose of the DTaP vaccine at no earlier than 6 weeks of age. Infants should receive a series of five vaccines by the age of 6 years. Individuals should receive an annual influenza vaccine to minimize the risk for infection with pertussis. The annual influenza vaccine does not protect individuals from infection with Bordetella pertussis. Individuals should still receive immunization against pertussis.

A nurse in an ED is caring for a client who is homeless and has hypothermia. Which of the following actions should the nurse take?

Initiate a referral to the facility's social worker. MY ANSWER The nurse should refer the client to the facility's social worker or to an agency that can assist the client with finding housing. Wrong Ask the client why they did not seek shelter sooner. Asking a "why" question can make the client defensive and is a barrier to effective communication. Tell the client everything will work out now that they are in the hospital. Telling the client everything will work out is giving the client false reassurance and does not address the client's immediate needs. Notify the local law enforcement agency of the client's situation. The nurse should only involve the local law enforcement agency when there is a legal issue.

An occupational health nurse in a factor is performing a routine TB screening and identifies an employee who has a positive Mantoux TB test. Which of the following actions should the nurse plan to take?

Instruct the employee that they will need to obtain a chest x-ray. MY ANSWER The presence of a positive Mantoux skin test can indicate the client has been exposed to the tuberculosis organism. A chest x-ray will determine if the disease is active or dormant. Wrong Initiate an employee immunization program. There are no immunizations for tuberculosis. Instruct the employee to wear an N95 respiratory mask. Health care providers of clients who have tuberculosis should wear an N95 respiratory mask to prevent exposure to the infection. Administer prophylactic penicillin to other employees. Prophylactic treatment for exposed individuals who test positive for tuberculosis does not include penicillin.

An occupational health nurse is planning to use an interpret during an educational session with a group of workers who speak a different language than the nurse. Which of the following actions should the nurse take?

Instruct the interpreter to guide the nurse in providing information in a culturally-sensitive manner is correct. The nurse should instruct the interpreter to give feedback to the nurse regarding the delivery of information that workers might find culturally sensitive to prevent insensitivity. Choose an interpreter who speaks the workers' language and dialect is correct. The nurse should choose an interpreter who can speak the workers' preferred language, including the specific dialect, in order to facilitate accurate communication. Evaluate the interpreter's approach to clients prior to the educational session is correct. The nurse should evaluate the style of the interpreter prior to the educational session to determine their ability to develop a trusting relationship with the workers in order to promote effective communication. Wrong Ask the interpreter to add information she feels might be necessary is incorrect. The nurse should ask the interpreter to not add or omit any information because it can interfere with the accuracy of the content. Encourage the interpreter to paraphrase the workers' questions and responses is incorrect. The nurse should ask the interpreter to translate the workers' comments and questions using their own words to increase the accuracy of the communication.

A school nurse is notified that a school-age child has pertussis. Which of the following actions should the school nurse take.

Instruct the parent to keep the child at home for 2 weeks after the initial symptoms first present is correct. The child should be kept at home until the coughing stage has passed because the disease is most communicable in this stage. Encourage family members to obtain prophylactic treatment is correct. Individuals who have been exposed to pertussis should be treated prophylactically with erythromycin, clarithromycin, or azithromycin. Check the immunization status of the child's classmates is correct. The immunization status of the child's classmates should be checked to identify the children who are at risk for acquiring the infection. Wrong Quarantine the children in the child's class is incorrect. While the nurse should place the client on droplet precautions, it is not necessary to quarantine the children in the child's class. Recommend that the child receive a pneumococcal vaccine in 28 days is incorrect. A pneumococcal vaccine is not effective against pertussis.

A nurse at a county health department is caring for a client who is at 28 weeks of gestation. The nurse should identify which of the following characteristics as a risk for potential future abuse of the newborn?

MY ANSWER Frequently changing health care providers is a risk factor for future child maltreatment because it can indicate that the client is experiencing partner violence and is attempting to hide it from the provider. Clients who experience violence are at a higher risk for perpetuating violence against their own children. Wrong Acceptance of the fetus, as demonstrated by selecting a name for the child, decreases the risk for future maltreatment of the child. Employment can contribute to economic stability, which decreases the risk for future maltreatment of the child. Having nightmares during pregnancy is not a risk factor for future maltreatment of a child. Anxieties about pregnancy, the developing fetus, and parenthood are an expected finding during pregnancy.

A nurse in a county health department is caring for a client who states, "I've been drinking too much in the evenings since my friend died last year." which of the following responses should the nurse take?

MY ANSWER The nurse is giving information to the client, which conveys a sense of caring. This also allows the nurse to provide additional information on resources that can help the client. Wrong The nurse is making a judgmental statement, which can make the client feel defensive. This statement will not encourage further communication with the client. The nurse is making a judgmental statement, which can make the client feel guilty. This statement will not encourage further communication with the client. "I don't think your friend would have approved of your drinking." The nurse is making a judgmental statement, which can make the client feel guilty. This statement will not encourage further communication with the client.

A nurse in a community center is preparing to administer a TB skin test to multiple clients to screen for tuberculosis. Which of the following actions should the nurse take?

MY ANSWER The nurse should inject 0.1 mL of purified protein derivative to form the wheal. Wrong The nurse should prepare the inner aspect of the forearm for the injection Insert the needle at a 45° angle. The nurse should inject the purified protein derivative intradermally, which requires a 5° to 15° angle. Create a wheal that measures about 15 mm in diameter. The nurse should create a wheal that is approximately 6 mm in diameter.

A home health care nurse is teaching a client's family about preventing the transmission of Clostridium difficile. Which of the following transmission-based precautions should the nurse include in the teaching?

MY ANSWER The nurse should instruct the family to implement contact precautions while providing care for a client who has Clostridium difficile. Contact precautions eliminate the exposure to contaminated body fluids and items. The nurse should implement droplet precautions when providing care for a client who has diphtheria or mumps. Droplet precautions require the use of appropriate hand hygiene, the wearing of a surgical mask when within 3 feet of the client, and the use of dedicated care equipment. The nurse should implement airborne precautions when providing care for a client who has varicella, pulmonary tuberculosis, or measles. This type of precaution requires a negative airflow room and the wearing of an N95 mask. Protective environment The nurse should implement protective environment precautions for clients who are highly susceptible to infections, such as clients who have severe dermatitis, major burns, leukemia, or who are undergoing chemotherapy.

A public health nurse is working in a community that has a population of 24,096. There are 2,096 existing cases of heart disease within the population. The nurse can determine which of the following from this information?

MY ANSWER The prevalence proportion can be calculated by using the number of people who were affected at a given time and the total population. Wrong Mortality rateThe mortality rate cannot be determined because the number of affected people who died is unknown. Attack rate The attack rate cannot be calculated because the population has not been exposed to a specific agent. Incidence proportion The incidence proportion cannot be calculated because the number of people newly diagnosed with heart disease over a period of time is not known.

A community health nurse is caring for a client who has opioid use disorder. The nurse should make a referral to this client to which of the following support groups?

Narcotics Anonymous (NA) MY ANSWER The nurse should instruct a client who has opioid use disorder to attend NA because opioids are a narcotic. This support group helps the client focus on the recovery process. Wrong Alcoholics Anonymous (AA) The nurse should instruct a client who has alcohol use disorder to attend AA. This support group helps the client to focus on the recovery process and to maintain sobriety. Nar-Anon The nurse should instruct the partner or family of a client who has an opioid use disorder to attend Nar-Anon. This support group provides self-help programs for the partners and family members of individuals who have an opioid use disorder. National Alliance on Mental Illness (NAMI) The nurse should be aware that NAMI is a family-led group which provides peer-led support for family members, caregivers, and loved ones of individuals who have mental illness.

A community health nurse is using statistical data to assess health outcomes in the local community. Which of the following measures is the nurse calculating when determining the TOTAL NUMBER OF deaths from stroke per total number of all deaths within the population over the prior 12 months?

Proportionate mortality ratio The nurse is calculating the proportionate mortality ratio, which is the number of deaths from a specific cause per the number of all deaths within a specific period of time. Wrong Cumulative incidence rate The cumulative incidence rate is the percentage of community members at risk for a disease who are diagnosed with the disease within a specific period of time. Crude mortality rate MY ANSWER The crude mortality rate is the proportion of deaths from any cause per the midyear population and is typically reported annually. Case fatality rate The case fatality rate is the percentage of a population diagnosed with a disease that die because of that disease within a specific period of time.

A nurse in a rural community is planning education for a young client who is a migrant farm worker. Which of the following actions should the nurse include?

Provide environmental health information is correct. Migrant farm workers are at risk for exposure to pesticides and other hazardous materials that could be harmful. Therefore, the nurse should include environmental health information in the client's education. Refer the client for a tuberculosis screening is correct. Rates of tuberculosis are estimated to be higher among migrant farm workers due to crowded living conditions and substandard housing. Therefore, the nurse should include a tuberculosis screening in the client's education. Recommend a dental health screening is correct. Dental problems are a primary health risk for migrant farm workers. Therefore, the nurse should include information about dental health in the client's education. Wrong Provide forms to apply for Medicare is incorrect. To be eligible for Medicare, individuals must meet an age requirement or be permanently disabled. Therefore, the nurse should not include Medicare information in the client's education.

A community health nurse is planning a health education program for adults. The nurse should plan to take which of the following actions during the program?

Provide take-home materials written at a 6th-grade level. MY ANSWER The American Medical Association and the National Institutes of Health recommend that take-home documents are written at a 6th- to 8th-grade level or lower to promote client understanding of the provided material. Wrong Use medical terminology throughout the presentation. The nurse should use common terms that the participants are likely to know and understand. Extend the presentation to include as much information as possible. Information sessions should be brief and to the point to maintain the attention of the participants. Avoid the use of technology to display images and videos. The use of images and videos can enhance comprehension and learning throughout the presentation.

A public health nurse is using the epidemiologic triangle to plan interventions for seasonal farmworkers in the community. Which of the following interventions is targeted at the host?

Providing farmworkers with gloves and hats to use when working Using the epidemiologic triangle, the host is considered the farmworkers. Providing farmworkers with gloves and hats to use when working helps provide personal protection from exposure to pesticides, chemicals, and ultraviolet light from the sun. Wrong Establishing regulations regarding the types of chemicals that can be used MY ANSWER Regulations regarding chemicals will affect the agent. Another potentially harmful agent that places the farmworkers at risk is exposure to biological pathogens. Preventing crowded working conditions Preventing crowded working conditions will affect the environment for the farmworkers. Another environmental factor is extreme temperature conditions. Encouraging farmworkers to limit the amount of time spent using vibrating equipment Limiting the time spent using vibrating equipment will affect the environment for the farmworkers. The leadership style and rules of managers are also considered environmental factors.

A community health nurse is creating a program to reduce violence in the community. Which of the following interventions should the nurse identify as secondary prevention?

Recognizing and reporting suspected abuse to the appropriate protective services MY ANSWER Secondary prevention is an intervention that focuses on early detection of a health problem to facilitate early diagnosis and treatment. Recognizing and reporting suspected abuse facilitates diagnosis and intervention, helping to prevent further abuse. Wrong Creating a public service announcement about the warning signs of partner abuse Public service announcements and other types of information sharing are examples of primary prevention, which includes interventions that are aimed at promoting health and preventing injury or illness. Collaborating with support agencies to ensure the ongoing treatment for abuse Collaborating with support agencies to ensure the ongoing treatment for abuse is an example of tertiary prevention, which includes interventions that are aimed at interrupting the course of a known disorder, reducing ensuing disability, and promoting rehabilitation. Educating individuals and groups about preventing domestic and community abuse Providing education about abuse is an example of primary prevention, which includes interventions that are aimed at promoting health and preventing injury or illness.

A community health nurse is made aware that several children, who are from the same family and did not receive immunizations, have contracted measles. Which of the following actions should the nurse take?

Report this information to the state health department. The CDC lists measles as a nationally notifiable disease. Requirements for reporting diseases are state mandated, rather than federally mandated. Therefore, the nurse should report this occurrence to the state health department, which then determines if it will report to the CDC. Wrong Encourage the family to keep the children isolated during the incubation period. MY ANSWER The period of incubation is 10 to 20 days. The children need to remain isolated for the period of communicability, which is from 4 days before to 5 days after the rash appears. Speak to the guardians about getting the children immunized after they are disease free. A measles infection provides a lifelong immunity, so the children will not need the immunization after they are disease free. The nurse cannot provide the names of the children to other children's parents and guardians because it is a violation of privacy. However, due to the highly contagious nature of the disease, the nurse should inform the school nurse that there are known cases and students might have been exposed. Prevention measures, such as referrals of children at risk, teaching proper handwashing, and immunization clinics, should be initiated.

A community health nurse is assigned to lead a county-level environmental task force. Which of the following activities should the nurse direct the task force to complete first?

Review community-specific epidemiological data. MY ANSWER The first action the nurse should direct the task force to take when using the nursing process is to conduct a community assessment, which includes a review of community-specific epidemiological data. The community assessment will assist the task force in identifying environmental health concerns within the county. Wrong Recommend updates to local environmental policies. The nurse should direct the task force to recommend updates to local policies if needed to ensure environmental standards are being met and to advocate for health promotion within the community. However, there is another action that the task force should complete first. Create program goals that align with Healthy People objectives. The nurse should direct the task force to create program goals that align with Healthy People to assist in achieving national-level objectives by minimizing health issues caused by the interaction of community members with the environment. However, there is another action that the task force should complete first. Distribute environmental health education materials to community members. The nurse should direct the task force to distribute environmental health education materials to community members to promote health and prevent diseases related to environmental concerns. However, there is another action that the task force should complete first.

A community health nurse is working as a member of a disaster response team following a biological incident. Which of the following actions should the nurse take?

Review surveillance reports to determine the effectiveness of the response. The nurse should review current surveillance reports to determine the effectiveness of disaster response efforts. Ongoing assessment and evaluation continue until the disaster recovery phase and are essential to ensure the success of response efforts. Wrong Immediately activate the Strategic National Stockpile for local use. The Strategic National Stockpile is activated through the dual efforts of the state and the public health system. The nurse does not have this level of authority. Review surveillance reports to determine the effectiveness of the response. The nurse should review current surveillance reports to determine the effectiveness of disaster response efforts. Ongoing assessment and evaluation continue until the disaster recovery phase and are essential to ensure the success of response efforts. Use a Geiger counter to detect exposure levels of first responders. MY ANSWER A Geiger counter is a device used to detect exposure to radiation, not biological agents.

A community health nurse is providing teaching about health promotion to a group of adolescents. Which of the following topics is the most important for the nurse to include in an attempt to lower adolescent mortality rates?

Safety belt useAutomobile crashes are currently the leading cause of death among adolescents. Therefore, this topic is most important to discuss when attempting to reduce premature deaths in this age group. Wrong Underage smoking MY ANSWER Underage smoking might lead to health complications later in life, but it is not the leading cause of death among adolescents. Safer sex practices Safer sex practices will reduce the incidence of pregnancy and sexually transmitted infections, but they will not affect the leading cause of death among adolescents. Heart-healthy diet An unhealthy diet might lead to health complications later in life, but it is not the leading cause of death among adolescents.

A charge nurse is orienting a group of newly hired nurses at a home health agency. Which of the following actions should the charge nurse include as an example of professional advocacy?

Sending opinion statements to legislators about laws that govern home health The charge nurse should include being active in the legislation process and maintaining an awareness of policies that might affect clients as part of professional advocacy. This allows the nurse to speak out on behalf of the home health clients to promote effective care. Wrong Maintaining licensing requirements for continuing education MY ANSWER The charge nurse should include participation in continuing education courses as part of accountability. Awareness of evidence-based trends in the nursing profession ensures that the nurse can deliver quality care to home health clients. Showing up at client homes during the time frame previously agreed upon The charge nurse should include this action as an example of fidelity, which relates to keeping promises and demonstrating loyalty to clients. Making client assignments based on staff preferences The charge nurse should discuss making assignments based on client preferences and needs as an example of advocacy.

A nurse is planning a community health project for a group of healthy older adult clients. Which of the following actions should the nurse plan as primary prevention activity?

Starting a weekly exercise group for participants MY ANSWER The nurse should include understanding medications, exercise, safety habits, nutrition, and the importance of regular health care visits when planning primary prevention for older adult clients. Wrong Scheduling bereavement support group meetings for participants The nurse should not plan to include bereavement support group meetings as a primary prevention activity. Bereavement support groups are a secondary prevention activity. Establishing a monthly clinic to monitor participant blood pressure The nurse should not plan to include blood pressure screening as a primary prevention activity. Blood pressure screenings are a secondary prevention activity. Screening each participant using a geriatric depression scale The nurse should not plan to include screening using a geriatric depression scale as a primary prevention activity. Depression screenings are a secondary prevention activity.

A nurse is conducting a home visit for an older adult client. The nurse should identify which of the following findings as an indicator of possible neglect?

Taking outdated prescriptions MY ANSWER The client taking outdated prescriptions is an example of inadequate medical care and is an indicator of possible neglect. Wrong Lives alone The fact that the client lives alone is not an indicator of possible neglect because many older adults live alone. However, if the client has a lack of access to basic necessities, such as food and water, then these findings would require further assessment. Has a BMI of 25 A BMI of 25 to 30 indicates that the client is overweight. Weight loss and malnourishment are indicators of possible neglect. Presence of alcohol in the home The presence of alcohol in the home is not an indicator of neglect. However, the nurse should assess the type and amount of alcohol that the client consumes to determine if further intervention is needed.

A community health nurse is participating in a group session for clients who have alcohol and substance abuse disorders. Which of the following information should the nurse provide regarding support programs for these individuals?

Teach a client who has vision loss about safety in the home environment. Teaching a client who has vision loss about safety in the home environment focuses on illness care for individuals. Therefore, this intervention is using a community-based approach. Wrong Alcoholics Anonymous (AA) is a support group that requires disclosure of attendance to employers. AA is a support group that can help clients who are addicted to alcohol and other substances. The intent of the support group is confidentiality and anonymity. Narcotics Anonymous (NA) is a one-on-one program that assists clients. NA is a support group that involves a group environment and social network for a client who is recovering from an addiction to opioids. Narcotics Anonymous (NA) will cure a client from their substance use disorder if they stays involved with the program. NA is a support group that helps clients understand the chronic nature of their addiction and learn to make changes in their life to stop using substances.

A home health nurse is conducting a follow-up visit for a client who was recently discharged from an acute rehabilitation program for alcohol use disorder. Which of the following actions should the nurse take?

Tell the client to take naltrexone daily. The nurse should instruct the client to take naltrexone daily to decrease cravings for alcohol. Naltrexone is prescribed to assist the client with alcohol withdrawal and prevent relapse. Wrong Instruct the client to take buprenorphine for the next 9 to 12 months. MY ANSWER Buprenorphine is prescribed for clients who are withdrawing from opiates. It is not used for the treatment of alcohol use disorder. Teach the client to avoid foods that contain tyramine. Clients who are prescribed monoamine oxidase inhibitors (MAOIs) are instructed to avoid foods that contain tyramine. MAOIs are prescribed for clients who have depression. Schedule transcranial magnetic stimulation (TMS) biweekly. TMS is used for the treatment of depression for clients who did not respond to other treatment interventions.

A nurse is conducting a home visit with a client who reports a history of partner violence. The nurse should identify that which of the following findings places the client at greatest risk for partner violence?

The client states they are leaving their partner. MY ANSWER A client's decision to leave their partner places them at greatest risk for partner violence because the perpetrator can view the client as a possession and fear loss of control. Whether the client actually leaves the relationship or just threatens to leave, the client is at greatest risk for violence during this time. Wrong The client is at 13 weeks of gestation. A pregnancy increases the client's risk for partner violence due to increased responsibility and feelings of jealousy by the perpetrator. However, there is another finding that places the client at greater risk for violence. The client recently started a new job. Starting a new job increases the client's risk for partner violence as this is an act of independence by the client. However, there is another finding that places the client at greater risk for violence. The client visits friends without the partner's knowledge. Visiting friends without knowledge of the partner increases the client's risk for partner violence as this is an act of independence by the client. However, there is another finding that places the client at greater risk for violence.

A home health nurse is visiting with an older client. Which of the following observations indicates the need for a home modification?

There are two rocking chairs in the living room. Rocking chairs and swivel chairs will require a modification. The nurse should block the motion of the chairs to keep them stable so that the client can easily get in and out. Wrong The home has power strips that have breakers. MY ANSWER Power strips with breakers and extension cords that are placed under sturdy furniture are examples of safety features that do not require modification. The client uses an electric toaster oven for cooking.Using a microwave or electric toaster oven for cooking, rather than a stove with open flames or hot burners, is a safety feature and does not require modification. The bathtub has a seat and a hand-held shower head. The use of a hand-held shower head, especially with a seat or bench, is a safety feature and does not require modification.

A nurse is preparing an education program about disaster preparedness for a community response team. Which of the following information should the nurse include about disaster triage?

Triage assists with the ethical allocation of available resources. MY ANSWER Disaster triage uses the principle of doing the most good for the most people. Resources are reserved for those who are most likely to survive with intervention, instead of for those whose condition is most critical. Wrong Triage takes place after clients are assigned a room in the emergency department. Triage begins immediately and typically at the scene of a disaster. A health care facility should establish a triage area prior to entry to the facility to triage clients arriving via emergency medical services (EMS), as well as clients arriving on their own. A client who has fixed and dilated pupils should receive priority care. A client who has fixed and dilated pupils should receive comfort measures only because survival is unlikely, even with immediate treatment. A client who has a tension pneumothorax is assigned to the delayed triage category. A client who is expectant is assigned to the immediate triage category because survival is likely with immediate treatment.

A nurse is preparing a health promotion handout for older adult clients about nutrition. Which of the following strategies should the nurse use when creating the handout?

Use a sixth-grade reading level. MY ANSWER The nurse should use a sixth- to eighth-grade reading level for written materials for older adult clients. This improves understanding of the handout information. Wrong Use a 12-point font. The nurse should use large print, which is at least 14-point font, for older adult clients. Written materials should also be bulleted. Use brightly colored paper. The nurse should use white or buff-colored paper with a dull matte finish to increase contrast and decrease the glare for older adult clients. Avoid the use of pictures. The nurse should include pictures as a method of visual stimulation to supplement the text in the handout.

A nurse in a pediatric clinic is providing care to several clients. The nurse should recognize that which of the following conditions is included on the Nationally Notifiable Infectious Conditions list?

Varicella The nurse should recognize that varicella is included on the Nationally Notifiable Infectious Conditions list. States voluntarily conduct surveillance and report instances of certain diseases to the Centers for Disease Control and Prevention so the data can be compiled and released each year. Wrong arlet fever MY ANSWER Scarlet fever is a contagious illness that is transmitted via direct contact with an individual who is infected or indirect contact with contaminated objects. However, it is not included on the Nationally Notifiable Infectious Conditions list. Erythema infectiosum Erythema infectiosum is a contagious illness that is transmitted via respiratory secretions and blood. However, it is not included on the Nationally Notifiable Infectious Conditions list. Rotavirus Rotavirus is a contagious illness that is transmitted via the fecal-oral route or by the person-to-person route. It causes a gastrointestinal infection and is the number one cause of diarrhea-associated hospital admissions in children. However, it is not included on the Nationally Notifiable Infectious Conditions list.

A nurse working in a local health department is providing home teaching to the guardian of a toddler who has atopic dermatitis and is experiencing sever pruritus. Which of the following instructions should the nurse give the guardian?

Wash the toddler's clothes in a mild detergent. MY ANSWER The nurse should instruct the guardian to launder the child's clothing in a mild detergent and ensure the clothes are thoroughly rinsed in clear water. The guardian should avoid using fabric softeners and products that decrease static cling because these can leave residue on the fabric, leading to increased irritation and itching. Wrong Give the toddler a bubble bath every 8 hr. Bubble baths and any harsh cleansers should be avoided. Also, excessive bathing can increase drying effects of the skin, causing pruritus to increase. The nurse should instruct the guardian to bathe the child in tepid water using a mild soap or emulsifying oil and apply an emollient within 3 min of bathing. Apply dry, warm compresses to the affected area. Dry, warm compresses will cause excessive drying of the toddler's skin and increase pruritus. The nurse should instruct the guardian to apply cool, moist compresses to the child's areas of inflammation. These create a soothing effect for the skin and provide antiseptic protection. Set the toddler's room thermostat at 27° C (80° F) at bedtime. Setting the toddler's room thermostat at 27° C at bedtime could cause perspiration and intensify itching. The nurse should instruct the guardian to avoid overheating the child to decrease the manifestations of pruritus. The room temperature should be set between 20° C to 22° C (68° F to 72° F).

A community health nurse is working with a group of clients in a rural community who are unable to afford health insurance. Which of the following actions is the best for the nurse to take to advocate for these clients?

Work with local health care practitioners to establish a free clinic. MY ANSWER According to evidence-based practice, the nurse should work with local health care practitioners to establish a free clinic in the rural community. The nurse should advocate for comprehensive care for this client population to address the need for an affordable health care option, which will allow clients who do not have health insurance to access a variety of primary, secondary, and tertiary services in one location. Wrong Provide for guaiac stool testing for clients who have a family history of colon cancer. Providing guaiac stool testing is a secondary prevention tool that can help to identify clients who are at risk for developing colon cancer. However, this only addresses one need for the community of uninsured clients. Perform weekly blood pressure screenings at the community center. Weekly blood pressure screenings are a secondary prevention tool that can help to identify clients who might have hypertension. However, this only addresses one need for the community of uninsured clients. Encourage the clients to form various exercise groups based on community interest. Forming exercise groups is a primary prevention tool that can improve the overall health of the clients in the community. However, this only addresses one need for the community of uninsured clients.

A home health nurse is planning care for the day. Which of the following clients should the nurse visit 1st?

A school-age child who was treated in the emergency department last night for status asthmaticus When using the airway, breathing, circulation approach to client care, the nurse should determine that the client who recently experienced status asthmaticus is the priority. The client's status can change rapidly, and, at times, intensive care monitoring is required. Therefore, the nurse should visit this client first. Wrong An older adult client who was treated in the emergency department last night for a stage 3 pressure injury The nurse should assess the client who has a stage 3 pressure injury to determine if further intervention is needed. However, there is another client that the nurse should visit first. An older adult client who has a newly prescribed antihypertensive medication and needs a BP checkMY ANSWERThe nurse should assess the client who has a newly prescribed antihypertensive medication to determine if the medication is effective. However, there is another client that the nurse should visit first. A school-age child whose percutaneous endoscopic gastrostomy (PEG) tube needs changing The nurse should assess the client whose PEG tube needs to be changed to meet the child's nutritional needs. However, there is another client that the nurse should visit first.

A nurse in a clinic is planning for a client who has a newly diagnosed with hepatitis C. Which of the following instructions should the nurse include in the teaching?

Abstain from sexual intercourse until antibody tests are negative. Hepatitis C is transmitted through sexual intercourse. Therefore, the nurse should instruct the client to abstain from sexual intercourse until antibody tests are negative. Wrong Consume a low-carbohydrate diet until symptoms resolve. The nurse should instruct the client to consume a diet that is high in carbohydrates and calories as part of the management of viral hepatitis. Schedule an appointment for an immunoglobulin injection. Postexposure prophylaxis is available for hepatitis A, not hepatitis C. Wear a mask in public places while receiving treatment. MY ANSWER Hepatitis C is transmitted through blood and body fluids. Therefore, it is not necessary for the client to follow airborne precautions.

A nurse is assessing the risks and benefits of meal delivery services for an older adult client who lives alone and has no transportation. Which of the following ethical principles is the nurse demonstrating?

Beneficence MY ANSWER The nurse is demonstrating the ethical principle of beneficence by determining if the client needs this service to maintain their health. Wrong Distributive justice The nurse would demonstrate the ethical principle of distributive justice by fairly determining which clients should receive meal delivery when there are a limited amount of services available for clients. Respect for autonomy The nurse would demonstrate the ethical principle of respect for autonomy by asking the client if they want this service and respecting the client's choice. Fidelity The nurse would demonstrate the ethical principle of fidelity by following through with initiating a referral, if it is determined that the client needs the service.

A nurse is developing a genogram for a client to determine education needs. Which of the following health risk information should the nurse expect to obtain with this tool?

Biological MY ANSWER A family genogram tracks the incidence of disease over multiple generations of a family and will identify biological risk factors. Wrong Behavioral To obtain information regarding behavioral risks, including personal and family health habits, the nurse should conduct a lifestyle risk assessment. Social To obtain information regarding social risks, including living in a high-stress environment like a high-crime neighborhood, the nurse should conduct an environmental risk assessment. Economic To obtain information regarding economic risks, including the relationship between family resources and the demand for those resources, the nurse should conduct an environmental risk assessment.