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A nurse in a community health clinic is preparing to administer an immunization
to a 5 year old child. which of the following actions should the nurse take?
a. Ask the child to pretend to blow up a balloon during the injection
b. Reassure the child that the injection is not going to hurt
c. Ask the child's parent to leave the room during the injection.
d. Request that the child count backwards from the number 10 during the
injection
answer: A
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.
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 finings places the
client at greatest risk for partner violence?
a. client is 13 weeks gestation
b. client states they are leaving their partner
c. client recently started a job
d. client visits friends without the partner's knowledge
answer: B
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.
A case manager is developing a plan for a client who has a spinal cord injury and
in a rehab facility. Which of the actions should the nurse take first?
,a. Hold a care conference with the client to discuss treatment options
b. Contact service providers to determine the availability of services offered.
c. Determine the client's ability to perform self-care
d. Evaluate the client's satisfaction with the case manager's services.
answer: C
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.
A community health nurse is planning to develop a community health program.
Which of the following actions should the nurse take first?
a. review literature
b. develop a budget
c. obtain resources
d. determine the need
answer: D
A case manager is planning an educational program fora. client who has diabetes
mellitus. Which of the following activities should the nurse include while using
the psychomotor domain of learning?
a. review a color diagram of the food pyramid with the client
b. show the client a video about how to monitor blood glucose levels
c. observe the client's technique for drawing up insulin
d. encourage the client to discuss their feelings of self worth
answer: C
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. A is cognitive
domain, B is cognitive domain, and D is affective domain
A nurse is caring for a client who has stage IV pancreatic cancer and has
received information regarding available treatment options. Which of the
following is the responsibility of the nurse if the client chooses to forgo treatment
and enter hospice care?
a. Make the hospice referral in accordance with the client's decision
, b. Verify that the client's health insurance pays for hospice services.
c. Recommend a second opinion from another provider.
d. Assess whether or not the family agrees with the client's decision
answer: A
The nurse should follow the ethical principle of respect for client autonomy and make
the hospice referral for the client.
A school nurse is conducting health screening procedures in an elementary
school. Which of the following instructions should she prcvide when performing
the Rinne test?
a. "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."
b. "Use your finger to close one ear while I whisper some numbers into your other
ear."
c. "After I place this tuning fork behind your ear, tell me when you no longer hear
the sound."
d. "You'll wear headphones and press the button when you hear a sound."
answer: C
A is a weber test, B is a whisper test, D is a audiometry test.
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 my neighbor has TB?"
Which of the following responses should the nurse make?
a. "You should ask the public health department."
b. "Do you have questions about tuberculosis?"
c. "Have you ever been tested for tuberculosis?"
d. "You should take precautions against this infection."
answer: B
This response addresses the neighbor's concerns while protecting the client's
confidentiality.
A public health nurse is conducting an educational session about Lyme disease
for a group of older adult clients. Which of the following statements should the
nurse identify as an indication that the clients understand the teaching?