ATI Community- leadership- disaster and Neuro
Total Questions : 45
Showing 25 questions, Sign in for moreA nurse is caring for a client brought to the Emergency Department as one of the first victims of a train accident. The nurse assesses the client, noting a respiratory rate of 38, a weak, rapid pulse, and uncontrolled bleeding. Using NATO guidelines, the nurse assigns which priority tag?
Explanation
Choice A: Red tag
A red tag is assigned to patients who require immediate medical attention and intervention to survive. These patients have life-threatening injuries but have a high chance of survival if treated promptly. In this scenario, the client has a respiratory rate of 38, a weak and rapid pulse, and uncontrolled bleeding. These symptoms indicate severe physiological distress and potential shock, necessitating immediate intervention to prevent death. According to NATO triage guidelines, such critical conditions warrant a red tag to prioritize urgent care1.
Choice B: Black tag
A black tag is used for patients who are deceased or have injuries so severe that survival is unlikely even with immediate medical intervention. This category is also known as “expectant” and is used to allocate resources to those with a higher chance of survival. The client in this scenario, despite having severe symptoms, is not described as being beyond the possibility of survival, thus a black tag would not be appropriate1.
Choice C: Green tag
A green tag is assigned to patients with minor injuries who can wait for medical treatment without immediate risk to life. These patients are often referred to as “walking wounded.” The client’s symptoms of a high respiratory rate, weak and rapid pulse, and uncontrolled bleeding are far too severe to be classified under this category. Assigning a green tag would delay critical care, potentially leading to fatal outcomes1.
Choice D: Yellow tag
A yellow tag is for patients who have serious injuries but whose treatment can be delayed without immediate risk to life. These patients need medical attention but are stable enough to wait for a short period. Given the client’s symptoms, particularly the uncontrolled bleeding and signs of shock, delaying treatment could result in rapid deterioration. Therefore, a yellow tag would not be suitable in this case1.
A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client?
Explanation
Choice A: A negative-pressure isolation room
A negative-pressure isolation room is typically used for patients with airborne infections, such as tuberculosis or measles, to prevent the spread of infectious agents through the air. Scabies, however, is primarily transmitted through direct skin-to-skin contact and occasionally through contact with contaminated clothing or bedding. Therefore, a negative-pressure isolation room is not necessary for a scabies patient1.
Choice B: A private room
A private room is the most appropriate choice for a client with scabies. This type of room helps prevent the spread of the infestation to other patients and allows for better control of the environment. Scabies is highly contagious and can spread through direct contact with the infested person or indirectly through contaminated items. Isolating the patient in a private room minimizes the risk of transmission and allows for proper infection control measures to be implemented2.
Choice C: A semi-private room with a client who has pediculosis capitis
Placing a scabies patient in a semi-private room with another patient, even one with a different parasitic infection like pediculosis capitis (head lice), is not advisable. Both conditions are highly contagious, and cohabitation increases the risk of cross-contamination and further spread of both infestations. Each condition requires specific treatment and isolation protocols to effectively manage and prevent outbreaks3.
Choice D: A positive-pressure isolation room
A positive-pressure isolation room is designed to protect immunocompromised patients from external contaminants by ensuring that air flows out of the room rather than in. This type of room is not suitable for a scabies patient, as it does not address the primary mode of transmission for scabies, which is direct contact. The focus for scabies management should be on preventing direct and indirect contact with others4.
A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client?
Explanation
Choice a reason:
A negative-pressure isolation room is designed to prevent the spread of airborne infectious diseases by ensuring that air flows into the room but not out of it. This type of room is typically used for patients with diseases such as tuberculosis, measles, or COVID-19, which are spread through airborne particles. Scabies, however, is spread through direct skin-to-skin contact or by sharing personal items like bedding or clothing. Therefore, a negative-pressure isolation room is not necessary for a patient with scabies, as the primary mode of transmission is not airborne.
Choice b reason:
A private room is the most appropriate setting for a client with scabies. Scabies is highly contagious and can spread through direct skin-to-skin contact or by sharing personal items. Placing the client in a private room helps to prevent the spread of the mites to other patients and staff. In a private room, the client can be isolated effectively, and healthcare workers can implement contact precautions, such as wearing gloves and gowns, to minimize the risk of transmission. This approach ensures that the client receives appropriate care while protecting others from potential exposure.
Choice c reason:
A semi-private room with a client who has pediculosis capitis (head lice) is not suitable for a client with scabies. Although both conditions involve infestations, they are caused by different parasites and have different modes of transmission. Pediculosis capitis is spread through direct contact with infested hair or personal items, while scabies is spread through prolonged skin-to-skin contact. Placing a client with scabies in a semi-private room with another infested patient increases the risk of cross-contamination and further spread of both conditions. Therefore, this option is not recommended.
Choice d reason:
A positive-pressure isolation room is designed to protect immunocompromised patients from airborne pathogens by ensuring that air flows out of the room but not into it. This type of room is used for patients who need to be protected from infections, such as those undergoing chemotherapy or with severe immune deficiencies. Since scabies is not an airborne disease and does not pose a risk to immunocompromised patients in this manner, a positive-pressure isolation room is not appropriate for a client with scabies. The primary concern with scabies is preventing direct contact transmission, which is best managed in a private room.
A nurse is delegating tasks to the assistive personnel (AP). The nurse should direct the AP to complete which of the following tasks first?
Explanation
Choice A reason:
Assisting a client with a bed bath who has a history of falls is important for maintaining hygiene and preventing skin breakdown. However, this task does not address an immediate physiological need. While it is essential to ensure the safety of clients with a history of falls, this task can be scheduled after more urgent needs are met. The priority in nursing care is to address tasks that have the most immediate impact on a client’s health and safety.
Choice B reason:
Providing a snack to a diabetic client who is feeling lightheaded is the most urgent task. Lightheadedness in a diabetic client can be a sign of hypoglycemia, which requires immediate intervention to prevent serious complications such as loss of consciousness or seizures. Hypoglycemia occurs when blood sugar levels drop too low, and providing a quick source of glucose can help stabilize the client’s condition. This task addresses an immediate physiological need and is critical for the client’s safety and well-being.
Choice C reason:
Feeding a client who has bilateral casts due to upper arm fractures is necessary to ensure the client receives adequate nutrition. However, this task does not address an immediate threat to the client’s health. While it is important to assist clients who are unable to feed themselves, this task can be performed after more urgent needs are addressed. Prioritizing tasks that address immediate physiological needs is essential in nursing care.
Choice D reason:
Ambulating a postoperative client for the first time is important for preventing complications such as deep vein thrombosis, pneumonia, and muscle weakness. Early ambulation is a key component of postoperative care and helps promote recovery. However, this task can be scheduled after addressing more immediate physiological needs. Ensuring the safety and stability of clients with urgent conditions takes precedence over routine postoperative care activities.
A nurse is caring for a client who was injured by a blast of high-order explosives. Medics report secondary injuries from the explosion. The nurse anticipates what type of injuries?
Explanation
Choice A reason:
Blunt force trauma refers to injuries caused by impact with a blunt object, resulting in contusions, abrasions, lacerations, or fractures. While blunt force trauma can occur in explosions, it is typically associated with tertiary blast injuries, where the victim is thrown against a solid object. Secondary injuries from high-order explosives are more specifically related to penetrating injuries caused by flying debris and shrapnel.
Choice B reason:
Hollow organ damage is a type of primary blast injury caused by the overpressure wave from an explosion. This wave can cause significant damage to gas-filled organs such as the lungs, intestines, and ears. However, secondary injuries are not typically characterized by hollow organ damage. Secondary injuries are more commonly associated with penetrating trauma from debris and shrapnel.
Choice C reason:
Post-trauma stress disorder (PTSD) is a psychological condition that can develop after experiencing or witnessing a traumatic event. While PTSD is a serious and common consequence of exposure to explosions and other traumatic events, it is not classified as a secondary injury. Secondary injuries refer to physical injuries caused by flying debris and shrapnel, not psychological conditions.
Choice D reason:
Penetrating injuries are the hallmark of secondary blast injuries. These injuries occur when fragments from the explosive device or surrounding materials are propelled at high velocity, causing wounds that penetrate the skin and underlying tissues. These injuries can be severe and life-threatening, requiring immediate medical attention. The nurse should anticipate and be prepared to manage penetrating injuries in clients exposed to high-order explosives.
A nurse advises a client with osteoporosis to have three servings of milk or dairy products daily. Which of the following levels of prevention is being used by the nurse?
Explanation
Choice A reason:
Secondary prevention involves early detection and treatment of disease to halt its progression. Examples include screening tests and early interventions. Advising a client with osteoporosis to consume dairy products is not aimed at early detection but rather at preventing the onset of complications by ensuring adequate calcium intake.
Choice B reason:
Primary prevention aims to prevent the onset of disease or injury before it occurs. This includes measures such as vaccinations, lifestyle modifications, and dietary recommendations. Advising a client with osteoporosis to consume three servings of milk or dairy products daily is a primary prevention strategy. It helps to maintain bone density and prevent fractures by ensuring adequate calcium and vitamin D intake.
Choice C reason:
Proactive prevention is not a standard term used in public health or medical practice. The recognized levels of prevention are primary, secondary, and tertiary. Therefore, this option is not applicable in this context.
Choice D reason:
Tertiary prevention focuses on managing and mitigating the effects of an existing disease to prevent further complications and improve quality of life. This includes rehabilitation and ongoing treatment for chronic conditions. While advising a client with osteoporosis to consume dairy products can be part of managing the condition, it is primarily a preventive measure to avoid further bone loss and fractures, aligning more with primary prevention.
A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?
Explanation
Choice A reason:
A gradual onset of headache is more characteristic of other types of headaches or conditions, such as tension headaches or migraines. Hemorrhagic strokes, particularly those caused by a ruptured cerebral aneurysm, typically present with a sudden and severe headache, often described as the “worst headache of my life.” This sudden onset is due to the rapid accumulation of blood in the brain, which increases intracranial pressure and causes immediate symptoms.
Choice B reason:
Changes in consciousness are a common manifestation of a hemorrhagic stroke. The sudden bleeding into the brain can disrupt normal brain function, leading to symptoms such as confusion, lethargy, or loss of consciousness. These changes occur rapidly and are a key indicator of a serious neurological event. The nurse should be vigilant for any alterations in the client’s level of consciousness, as this can signify worsening of the condition and the need for immediate medical intervention.
Choice C reason:
A gradual onset of several hours is not typical for hemorrhagic strokes. These strokes usually present with sudden and severe symptoms due to the abrupt rupture of a blood vessel in the brain. The rapid increase in intracranial pressure from the bleeding causes immediate and severe symptoms, rather than a slow progression over hours.
Choice D reason:
A history of neurologic deficits lasting less than 1 hour is more indicative of a transient ischemic attack (TIA), also known as a mini-stroke. TIAs are temporary and resolve within a short period without causing permanent damage. In contrast, a hemorrhagic stroke caused by a ruptured cerebral aneurysm results in immediate and severe symptoms that do not resolve quickly and require urgent medical attention.
A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching?
Explanation
Choice A reason:
Inserting a padded tongue blade into the client’s mouth is not recommended and can be dangerous. During a seizure, there is a risk of causing injury to the client’s mouth or teeth, and it can also obstruct the airway. The correct approach is to ensure the client’s safety by preventing injury, not by inserting objects into their mouth.
Choice B reason:
Restraining the client during a seizure is not advised. Restraints can cause additional harm and do not prevent the seizure from occurring. Instead, the focus should be on protecting the client from injury by ensuring a safe environment and allowing the seizure to run its course.
Choice C reason:
Moving objects away from the client is a crucial step in ensuring their safety during a seizure. This action helps prevent the client from hitting or injuring themselves on nearby objects. Creating a safe space around the client is one of the primary goals during a seizure to minimize the risk of injury.
Choice D reason:
Placing the client on their back is not recommended during a seizure. Instead, the client should be placed on their side if possible, to help keep the airway clear and reduce the risk of aspiration. This position also allows for better monitoring of the client’s breathing and overall condition.
The nurse is preparing for an initial home care visit for a client with diabetes. Which action by the nurse is appropriate? SELECT ALL THAT APPLY.
Explanation
Choice A reason:
Going automatically into the client’s bedroom without permission is inappropriate and can be seen as an invasion of privacy. The nurse should always seek consent and respect the client’s personal space. Building trust and maintaining professional boundaries are crucial in home care settings.
Choice B reason:
While it is courteous to thank the client for arranging a home visit, it is not a critical action that directly impacts the care provided. The focus should be on assessing the client’s needs and establishing a care plan.
Choice C reason:
Arranging mutual future visits is an appropriate action. It helps to establish a consistent care schedule, ensuring that the client receives ongoing support and monitoring. This is particularly important for managing chronic conditions like diabetes, where regular follow-up is essential for effective management.
Choice D reason:
Asking how the client is managing at home is a crucial part of the initial assessment. It provides the nurse with valuable information about the client’s current health status, challenges, and needs. This information is essential for developing a personalized care plan that addresses the client’s specific circumstances.
Choice E reason:
Sitting down and discussing with the client and family members is an important step in the initial home care visit. It helps to build rapport, understand the client’s support system, and involve family members in the care process. This collaborative approach ensures that everyone is informed and can contribute to the client’s care and well-being.
Which of the following statements indicate the importance of epidemiology to the community health nurse? SELECT ALL THAT APPLY.
Explanation
Choice A reason:
While epidemiology provides valuable data that can inform public health policies and legislation, it does not directly interpret legislation. The role of epidemiology is to gather and analyze data on health outcomes, which can then be used by policymakers to create informed legislation. Therefore, this statement does not accurately reflect the primary functions of epidemiology.
Choice B reason:
Epidemiology evaluates the effectiveness of nursing interventions by analyzing data on health outcomes before and after the implementation of specific interventions. This helps determine whether the interventions are successful in improving health and reducing disease incidence. Community health nurses rely on this data to make evidence-based decisions and improve their practice.
Choice C reason:
Epidemiology analyzes and examines the root causes of health outcomes by studying patterns, causes, and effects of health and disease conditions in populations. This analysis helps identify risk factors and underlying causes of diseases, which is essential for developing effective prevention and intervention strategies.
Choice D reason:
Epidemiology defines the burden of disease and determinants of health by quantifying the incidence, prevalence, and impact of diseases within a population. This information is crucial for public health planning and resource allocation, as it highlights the most pressing health issues and their contributing factors.
Choice E reason:
Epidemiology relates to the health status of a population by providing comprehensive data on health trends, disease outbreaks, and overall health outcomes. This information helps community health nurses understand the health needs of their populations and tailor their interventions accordingly.
A nurse is assessing a client who reports a severe headache and stiff neck. The nurse’s assessment reveals positive Kernig’s and Brudzinski’s signs. Which of the following actions should the nurse perform first?
Explanation
Choice A reason:
Decreasing bright lights can help alleviate discomfort for the client, especially if they are experiencing photophobia, which is common in meningitis. However, this action does not address the immediate need to prevent the spread of infection. While it is a supportive measure, it is not the first priority in managing a client with suspected meningitis.
Choice B reason:
Implementing droplet precautions is the first priority when a client presents with symptoms suggestive of meningitis, such as a severe headache, stiff neck, and positive Kernig’s and Brudzinski’s signs. Meningitis can be caused by bacterial infections that are highly contagious and spread through respiratory droplets. Initiating droplet precautions helps prevent the transmission of the infection to other clients and healthcare workers, making it the most critical initial action.
Choice C reason:
Initiating IV access is important for administering medications and fluids, but it is not the first priority. Ensuring the safety of others by implementing droplet precautions takes precedence. Once precautions are in place, the nurse can proceed with establishing IV access to facilitate further treatment.
Choice D reason:
Administering antibiotics is crucial in the treatment of bacterial meningitis, but it should be done after droplet precautions are in place to prevent the spread of infection. Prompt antibiotic therapy is essential, but the initial step must focus on infection control measures to protect others from exposure.
A nurse is assessing a client who was brought into the emergency room following a seizure. The nurse suspects the client may have meningococcal meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next?
Explanation
Choice A reason:
Administering an antipyretic can help reduce fever, which is a common symptom of meningococcal meningitis. However, this action does not address the immediate need to assess the extent of neurological impairment. While fever management is important, it is not the first priority in this situation.
Choice B reason:
Completing a vascular assessment is important to evaluate the client’s circulatory status, especially if there are signs of septicemia. However, in the context of suspected meningococcal meningitis, the priority is to assess the neurological status to determine the extent of central nervous system involvement. This will guide further treatment and interventions.
Choice C reason:
Assessing the cranial nerves is crucial in a client with suspected meningococcal meningitis. This assessment helps determine the extent of neurological impairment and can provide critical information about the progression of the disease. Early identification of neurological deficits can guide immediate and appropriate interventions to prevent further complications.
Choice D reason:
Decreasing environmental stimuli can help reduce discomfort for the client, especially if they are experiencing photophobia or other sensory sensitivities. However, this action does not address the immediate need to assess the client’s neurological status. It is a supportive measure that can be implemented after more critical assessments are completed.
A community health nurse is teaching a group of nursing students about descriptive analytics. The nurse recognizes that which of the following best describes the purpose of descriptive analytics in nursing?
Explanation
Choice A reason:
Predicting future client outcomes based on historical data is the purpose of predictive analytics, not descriptive analytics. Predictive analytics uses statistical models and algorithms to forecast future events or behaviors. Descriptive analytics, on the other hand, focuses on summarizing and interpreting past data.
Choice B reason:
Developing new treatment protocols based on client data is more aligned with prescriptive analytics, which provides recommendations for actions based on data analysis. Descriptive analytics does not develop new protocols but rather helps in understanding and summarizing existing data.
Choice C reason:
Descriptive analytics involves summarizing and interpreting historical client data to identify trends and patterns. This type of analytics helps healthcare providers understand what has happened in the past and can inform decision-making by highlighting key insights and trends. It is a foundational step in data analysis that supports further predictive and prescriptive analytics.
Choice D reason:
Providing real-time monitoring of client’s vital signs is associated with real-time analytics or monitoring systems, not descriptive analytics. Descriptive analytics focuses on analyzing historical data rather than real-time data.
A nurse is providing care to a client with Myasthenia gravis who has lost 6 kg of weight over the past 2 months. What should the nurse suggest to improve this client’s nutritional status?
Explanation
Choice A reason:
Restricting drinking fluids before and during meals is not an appropriate suggestion for improving nutritional status. While it might help prevent early satiety in some cases, it does not address the underlying issues related to Myasthenia gravis, such as muscle weakness affecting chewing and swallowing.
Choice B reason:
Planning medication doses to occur before meals is a crucial strategy for clients with Myasthenia gravis. Medications such as anticholinesterase agents can help improve muscle strength, making it easier for the client to chew and swallow food. This approach can enhance the client’s ability to consume adequate nutrition during meals.
Choice C reason:
Increasing the amount of fat and carbohydrates in meals might help with caloric intake, but it does not address the specific challenges faced by clients with Myasthenia gravis. The focus should be on strategies that improve the client’s ability to eat effectively, rather than just altering the macronutrient composition of meals.
Choice D reason:
Eating three large meals per day can be challenging for clients with Myasthenia gravis due to muscle fatigue. Smaller, more frequent meals are often recommended to help manage energy levels and ensure adequate nutrition without overwhelming the client.
A nurse is working with a community at risk for flooding. The nurse is aware that identification of at-risk populations, education of the residents about evacuation routes, and emergency shelters is an example of what level of the National Response Framework?
Explanation
Choice A reason:
The security phase is not a recognized phase in the National Response Framework. The framework focuses on preparedness, response, recovery, and mitigation phases. Security measures are integrated into these phases but are not a standalone phase.
Choice B reason:
The mitigation phase involves actions taken to reduce the impact of disasters before they occur. This includes identifying at-risk populations, educating residents about evacuation routes, and establishing emergency shelters. These proactive measures help minimize the potential damage and enhance community resilience.
Choice C reason:
The response phase involves actions taken during and immediately after a disaster to ensure safety and provide emergency assistance. While important, the activities described in the question are more aligned with mitigation efforts that occur before a disaster strikes.
Choice D reason:
The practice phase is not a recognized phase in the National Response Framework. However, preparedness activities, including drills and exercises, are part of the overall framework to ensure readiness for potential disasters.
A registered nurse (RN) and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the RN delegate to the LPN? SELECT ALL THAT APPLY
Explanation
Choice A reason:
Monitoring vital signs of postoperative clients is a task that can be safely delegated to an experienced LPN. LPNs are trained to monitor and report vital signs, which is a routine and essential part of postoperative care. This task does not require the advanced assessment skills of an RN, making it appropriate for delegation.
Choice B reason:
Administering routine medications to stable clients is within the scope of practice for LPNs. They are trained to administer medications and monitor clients for adverse reactions. As long as the clients are stable and the medications are routine, this task can be delegated to an LPN.
Choice C reason:
Performing wound care on a client with a Stage III pressure ulcer is a task that an experienced LPN can perform. LPNs are skilled in wound care and can manage complex dressings and treatments under the supervision of an RN. This delegation allows the RN to focus on more complex tasks that require their advanced skills.
Choice D reason:
Developing a teaching plan for a client newly diagnosed with Type II Diabetes is a task that should not be delegated to an LPN. This task requires comprehensive knowledge of diabetes management, patient education, and individualized care planning, which are within the RN’s scope of practice. The RN should develop the teaching plan and may involve the LPN in reinforcing the education.
Choice E reason:
Providing oral care to an unconscious client is a task that can be delegated to an experienced LPN. Oral care is essential for preventing infections and maintaining hygiene, and LPNs are trained to perform this care safely and effectively.
A nurse is working with the hospital disaster plan with the emergency operations committee. The nurse is aware that nursing is involved in which components of the disaster plan? SELECT ALL THAT APPLY
Explanation
Choice A reason:
Identification of resources to meet anticipated needs is a critical component of disaster planning. Nurses play a key role in identifying the resources required for effective disaster response, including medical supplies, personnel, and equipment. This ensures that the hospital is prepared to meet the needs of patients during a disaster.
Choice B reason:
Participation in comprehensive annual drills is essential for disaster preparedness. Nurses are involved in these drills to practice and refine their response skills, ensuring they are ready to act effectively in a real disaster. Drills help identify gaps in the disaster plan and provide opportunities for improvement.
Choice C reason:
Internal and external communications are vital during a disaster. Nurses are involved in establishing and maintaining communication channels within the hospital and with external agencies. Effective communication ensures coordination and timely response, which are crucial for managing a disaster situation.
Choice D reason:
Performing duties outside the typical job description may occur during a disaster, but it is not a primary component of the disaster plan. The focus is on ensuring that all staff are prepared to perform their roles effectively. While flexibility is important, the disaster plan should primarily outline specific roles and responsibilities.
Choice E reason:
Development of a decontamination plan is an important aspect of disaster preparedness, especially in scenarios involving hazardous materials. Nurses contribute to creating and implementing decontamination protocols to protect patients and staff from exposure to harmful substances.
A nurse is determining if a homebound client is eligible for Meals-on-Wheels. Which of the following is the most important factor for the nurse to consider?
Explanation
Choice A reason:
The client’s level of family support is important, but it is not the most critical factor in determining eligibility for Meals-on-Wheels. Family support can supplement the client’s needs, but the primary focus should be on the client’s ability to prepare meals independently.
Choice B reason:
The client’s financial resources are a consideration, but many Meals-on-Wheels programs offer services on a sliding scale or free of charge based on need. Financial resources alone do not determine eligibility; the ability to prepare meals is a more direct indicator of need.
Choice C reason:
The client’s access to transportation is relevant, especially if they need to travel to obtain food. However, Meals-on-Wheels is designed to serve homebound clients who cannot easily leave their homes, making transportation less of a concern compared to the ability to prepare meals.
Choice D reason:
The client’s ability to prepare meals is the most important factor in determining eligibility for Meals-on-Wheels. This program is specifically designed to assist individuals who are unable to prepare nutritious meals for themselves due to physical or cognitive limitations. Ensuring that clients receive adequate nutrition is the primary goal of the program.
A nurse is delegating tasks to assistive personnel. Which of the following should the nurse consider when using one of the five rights of delegation?
Explanation
Choice A reason:
The assistive personnel’s ability to complete the task without assistance is important, but it is encompassed within the broader consideration of their competency and experience. Ensuring that the personnel can perform the task independently is part of assessing their overall capability.
Choice B reason:
The assistive personnel’s level of experience and competency in performing the task is a critical factor in the delegation process. The nurse must ensure that the personnel have the necessary skills and knowledge to perform the task safely and effectively. This consideration aligns with the “right person” aspect of the five rights of delegation, ensuring that the task is delegated to someone who is qualified to perform it.
Choice C reason:
The assistive personnel’s rapport with clients is beneficial for providing compassionate care, but it is not a primary consideration in the delegation process. The focus should be on the personnel’s ability to perform the task competently and safely.
Choice D reason:
The assistive personnel’s availability at the time of the delegation is a logistical consideration, but it does not address the critical aspect of competency. While availability is necessary, it is secondary to ensuring that the personnel are capable of performing the task.
The school nurse identifies 12 students with confirmed cases of influenza A. The families of the children are advised to keep the children home for a minimum of 5 to 7 days. Which of the following is an appropriate action by the nurse?
Explanation
Choice A reason:
Closing the school for 6 weeks is an extreme measure that is not typically warranted for managing influenza outbreaks. Public health guidelines usually recommend temporary closures or other measures to control the spread of infection, but a 6-week closure is excessive and disruptive.
Choice B reason:
Education regarding respiratory and hand hygiene is an appropriate and effective action to help control the spread of influenza. Teaching students and staff about proper handwashing techniques, respiratory etiquette, and other preventive measures can significantly reduce the transmission of the virus. This approach empowers the school community to take proactive steps in preventing further infections.
Choice C reason:
Discipline in the school setting for improper handwashing is not an appropriate response. While it is important to encourage proper hygiene practices, using disciplinary measures can create a negative environment and may not effectively promote behavior change. Education and positive reinforcement are more effective strategies.
Choice D reason:
Running a mandatory flu clinic can be beneficial, but it is not the most immediate or appropriate action in response to an outbreak. Flu clinics are typically part of broader vaccination efforts and may not address the immediate need to control the current outbreak. Education on hygiene practices is a more immediate and practical response.
A nursing preceptor is reviewing life expectancy in the twentieth century with a new nurse. The nurse should recognize that which of the following was most responsible for the dramatic increase in life expectancy during the twentieth century?
Explanation
Choice A reason:
The use of antibiotics to fight infections significantly improved health outcomes and reduced mortality rates from bacterial infections. However, antibiotics were not widely available until the mid-20th century. The dramatic increase in life expectancy began earlier, largely due to improvements in public health measures.
Choice B reason:
Sanitation and other public health activities were most responsible for the dramatic increase in life expectancy during the twentieth century. Improvements in sanitation, such as clean water supply, sewage treatment, and waste disposal, drastically reduced the incidence of infectious diseases. Public health initiatives, including vaccination programs and health education, also played a crucial role in preventing disease and promoting health.
Choice C reason:
Technology increases in the field of medical laboratory research have contributed to advancements in medical knowledge and treatment. While these technological advancements have improved diagnostic capabilities and treatment options, they were not the primary drivers of the initial increase in life expectancy during the early 20th century.
Choice D reason:
Advances in surgical techniques and procedures have significantly improved outcomes for many medical conditions. However, these advances primarily benefited individuals who had access to surgical care and did not have as widespread an impact on overall life expectancy as public health measures did.
A nurse is teaching a client who has a new prescription for Sumatriptan (Imitrex) tablets to treat migraine headaches. Which of the following instructions should the nurse include?
Explanation
Choice A reason:
Chewing the tablet before swallowing is not the correct method of administration for Sumatriptan (Imitrex) tablets. These tablets are designed to be swallowed whole. Chewing them could affect the medication’s efficacy and absorption.
Choice B reason:
“If you experience chest pain, call your physician immediately.” This instruction is crucial because Sumatriptan can cause serious cardiovascular side effects, including chest pain, which may indicate a heart attack or other serious condition. Clients need to be aware of this potential side effect and seek immediate medical attention if it occurs.
Choice C reason:
Taking Sumatriptan daily to prevent headaches is incorrect. Sumatriptan is used to treat acute migraine attacks and is not intended for daily use as a preventive medication. Using it daily could lead to medication overuse headaches and other adverse effects.
Choice D reason:
“Repeat dose in 1 hour for unrelieved headache” is partially correct but incomplete. The correct instruction is to repeat the dose after 2 hours if the headache is not relieved, up to a maximum of two doses in 24 hours. Clients should follow the specific dosing instructions provided by their healthcare provider.
A nurse is caring for a client scheduled for a functional assessment who asks, “What is the purpose of this assessment?” How should the nurse most appropriately respond to the client?
Explanation
Choice A reason:
“It is a test that determines which activities you feel most comfortable performing” is not entirely accurate. While comfort with activities may be assessed, the primary goal of a functional assessment is to evaluate the client’s ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs).
Choice B reason:
“It is a tool that is used to determine your maximum level of self-sufficiency.” This response accurately reflects the purpose of a functional assessment. The assessment evaluates the client’s ability to perform ADLs and IADLs independently, which helps determine the level of assistance they may need.
Choice C reason:
“It is a tool that is used to assess what services you will need a home health aide to perform for you” is partially correct but not comprehensive. While the assessment can help identify the need for home health aide services, its primary purpose is to evaluate overall self-sufficiency and functional status.
Choice D reason:
“It is a tool used by insurance companies to determine qualifications for medical reimbursement” is not the primary purpose of a functional assessment. Although the results may be used for insurance purposes, the main goal is to assess the client’s functional abilities and needs.
The nurse is performing the Romberg test on a client during a neurological assessment. Which of the following best describes the rationale for conducting the Romberg test?
Explanation
Choice A reason:
The Romberg test is not used to measure respiratory rate and depth. Respiratory assessments involve observing breathing patterns, rate, and depth, which are unrelated to the Romberg test.
Choice B reason:
While the Romberg test can provide some information about coordination, its primary purpose is not to evaluate fine motor skills. Fine motor skills are typically assessed through tasks that involve precise hand and finger movements.
Choice C reason:
The Romberg test is used to test for proprioception and vestibular function. It assesses the client’s ability to maintain balance with their eyes closed, which helps identify issues with proprioception (the sense of body position) and vestibular function (the inner ear’s role in balance).
Choice D reason:
The Romberg test does not assess cranial nerve function related to facial expression. Cranial nerve assessments involve specific tests for each nerve, such as asking the client to smile or raise their eyebrows to evaluate facial nerve function.
A nurse is caring for a client diagnosed with Trigeminal neuralgia who is suddenly experiencing severe pain on the left side of the face. The nurse identifies which classification of medications is most effective in treating this type of pain?
Explanation
Choice A reason:
Analgesics, such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), may provide some relief for mild pain but are generally not effective for the severe, neuropathic pain associated with Trigeminal neuralgia. This condition requires medications that specifically target nerve pain.
Choice B reason:
Antibiotics are used to treat bacterial infections and are not effective for treating neuropathic pain conditions like Trigeminal neuralgia. This type of pain is not caused by an infection, so antibiotics would not be appropriate.
Choice C reason:
Anticonvulsants, such as carbamazepine and gabapentin, are the most effective medications for treating Trigeminal neuralgia. These drugs help stabilize nerve activity and reduce the frequency and intensity of pain episodes. They are considered the first-line treatment for this condition.
Choice D reason:
Antihistamines are used to treat allergic reactions and are not effective for neuropathic pain. They do not have the properties needed to manage the severe pain associated with Trigeminal neuralgia.
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