Preview Extract
Community Health ATI
1. During a home health visit a school age child who has muscular dystrophy confides in the
nurse that he was struck by his parents. which of the following actions should the nurse take
first?
a. report the incident to local authorities
b. check the child for injuries
c. refer the parent to a social service agency
d. enroll the parent in anger management classes.
Answer: b. check the child for injuries
Rationale:
The first priority in this situation is to ensure the safety and well-being of the child. Checking the
child for injuries is important to assess the extent of harm and to provide immediate care if
needed. This step should be taken before reporting the incident to local authorities, referring the
parent to a social service agency, or enrolling the parent in anger management classes.
2. a nurse is planning a program about healthy eating at an elementary school where most
students select French fries and pizza at lunch every day. which of the following actions should
the nurse plan to take first?
a. give positive feedback to students who make appropriate choices.
b. help students recognize the value of making healthy food choices
c. provide students with resources about making wise choices independently
d. determine student’s motivation to learn about healthy food choices.
Answer: d. determine student’s motivation to learn about healthy food choices.
Rationale:
Before implementing any educational program, it is important to assess the audience's readiness
and motivation to learn. Understanding the students' perspectives and attitudes towards healthy
eating will help the nurse tailor the program effectively. Giving positive feedback, helping
students recognize the value of healthy choices, and providing resources can come after
assessing their motivation.
3. a nurse manger in local community health agency is creating a job description for a new nurse
who will practice community oriented nursing. which of the following should the nurse include
in the job description? (select all that apply)
a. investigate potential health and environmental issues
b. initiate support groups for parents of autistic children
c. provide wound care for clients in their homes
d. participate in local health surveillance activities
e. provide health related education to community groups
Answer: a. investigate potential health and environmental issues
b. initiate support groups for parents of autistic children
d. participate in local health surveillance activities
e. provide health related education to community groups
Rationale:
• Investigating potential health and environmental issues is crucial for identifying and addressing
community health concerns.
• Initiating support groups for parents of autistic children can provide valuable social and
emotional support.
• Participating in local health surveillance activities helps monitor and track community health
trends.
• Providing health-related education to community groups promotes health literacy and
empowers individuals to make informed decisions about their health.
4. a community health nurse is planning an educational program for a group of women who are
postmenopausal. which of the following outcomes is appropriate for this program?
a. clients will schedule bone density screening
b. clients will arrange for mammograms every 3 years
c. clients will start hormone replacement therapy
d. clients will significantly decrease caloric intake
Answer: a. clients will schedule bone density screening
Rationale:
Postmenopausal women are at increased risk for osteoporosis, making bone density screening
important for early detection and prevention of fractures. Encouraging clients to schedule these
screenings aligns with preventive health measures for this population. Mammograms, hormone
replacement therapy, and caloric intake are also important health considerations but may not be
the primary focus for this specific educational program.
5. a nurse is working with a care manager for a client who participates in a health maintenance
organization. the nurse should identify that a health maintenance organization provides which of
the following payment structures.
a. the client is participating in a fee for service health care insurance program
b. the provider is paid a fixed sum for the client on a monthly or yearly basis
c. the client pays the insurer a percentage of the total costs for each service rendered by the
provider
d. the provider bills the client directly for a predetermined percentage of the cost of services
Answer: b. the provider is paid a fixed sum for the client on a monthly or yearly basis
Rationale:
In an HMO, the provider (healthcare organization) receives a fixed payment per client (member)
for a set period (monthly or yearly). This payment structure incentivizes providers to focus on
preventive care and cost-effective treatments to maintain the health of their clients, as opposed to
fee-for-service models where providers are paid based on the number of services they deliver.
6. a client who has diabetes mellitus asks a home health nurse to help her adapt some of her
traditional cultural foods to fit her meal plan. which of the following is the first action the nurse
should take when assisting this client?
a. provide the client with a printed recipe
b. observe the client during preparation of traditional foods
c. use cookbooks to include traditional foods in meal plans
d. explain diabetes exchange list
Answer: b. observe the client during preparation of traditional foods
Rationale:
Observing the client during food preparation allows the nurse to understand the client's current
cooking practices, ingredients used, and portion sizes. This information is crucial for making
appropriate modifications to the client's meal plan. Providing a printed recipe, explaining
diabetes exchange lists, and using cookbooks can be helpful but should come after observing the
client's current practices.
7. a home health nurse manager is caring for a client who has methicillin resistant
staphylococcus aureus. which of the following actions should the nurse take?
a. remove fresh flowers from the client’s home
b. wear a mask when within 3 feet of the client
c. encourage the client to use a hepa filter in the house
d. double bag soiled dressing in polyethylene bags.
Answer: d. double bag soiled dressing in polyethylene bags.
Rationale:
Double bagging soiled dressing helps contain the infectious material and reduce the risk of
transmission to others. Removing fresh flowers, wearing a mask, and encouraging the client to
use a HEPA filter may be appropriate infection control measures in certain situations, but they
are not specific to managing MRSA.
8. an occupational health nurse is discussing health promotion with a client who has a history of
obesity. which of the following comments indicates the client is using rationalization as a coping
mechanism?
a. i have lots of health problems from being obese
b. I am obese it’s in my genes
c. i have difficulty resisting the items in vending machines
d. i know you don’t like me because i am obese
Answer: b. I am obese it’s in my genes
Rationale:
Rationalization is a defense mechanism where an individual justifies their behavior or feelings
with socially acceptable explanations rather than addressing the real issue. Blaming genetics for
obesity is an example of rationalization.
9. a nurse is conducting a community assessment. which of the following information should the
nurse include as part of the windshield survey?
a. demographic data
b. mortality rate
c. informant interviews
d. housing quality
Answer: d. housing quality
Rationale:
A windshield survey involves observing the community from the perspective of a moving
vehicle. Assessing housing quality, along with other observable characteristics such as
cleanliness, safety, and infrastructure, provides valuable information about the community's
living conditions.
10. a community health nurse is educating a parent about the importance of hepatitis B
immunization. which of the following explanations should the nurse give the parent about the
disease?
a. one dose of the immunization gives children lifelong protection from hepatitis B
b. hepatitis B spreads easily among children through casual contact
c. many people who acquire acute hepatitis B develop chronic hepatitis
d. people who have had a hepatitis B infection still need the immunization
Answer: c. many people who acquire acute hepatitis B develop chronic hepatitis
Rationale:
Hepatitis B can lead to chronic infection, which increases the risk of developing liver disease,
including cirrhosis and liver cancer. Vaccination is important to prevent the transmission of
hepatitis B and its potential long-term complications.
11. a first response team is working at the location of a bombing incident. a nurse triaging a
group of clients should give treatment priority to which of the following clients.
a. a client who has superficial partial thickness burn injuries over 5% of his body
b. a client who has a femur fracture with a 2+ pedal pulse
c. a client who is ambulatory and exhibits manic behavior
d. a client who has a rigid abdomen with manifestations of shock.
Answer: d. a client who has a rigid abdomen with manifestations of shock.
Rationale:
A rigid abdomen with signs of shock suggests internal injuries, which require immediate medical
attention to prevent further complications. Superficial burns, a femur fracture with a palpable
pedal pulse, and manic behavior, while important, do not indicate immediate life-threatening
conditions like a rigid abdomen with shock.
12. a nurse is working with a community health care team to devise strategies for preventing
violence in the community. which of the following interventions is an example of tertiary
prevention?
a. presenting community education programs about stress management
b. developing resources for victims of abuse
c. urging community leaders to make nonviolence a priority
d. assessing for risk factors of intimate partner abuse during health examinations
Answer: b. developing resources for victims of abuse
Rationale:
Tertiary prevention aims to minimize the negative impact of a disease or condition that has
already occurred. Providing resources for victims of abuse helps to support and assist individuals
who have experienced violence, thereby reducing the long-term consequences of the abuse.
13. public health nurse take
a. alert the family members of coworkers about possible exposure to anthrax
b. place the employee under quarantine for 14 days
c. refer coworkers who might have been exposed to a provider for prophylactic antibiotics
d. instruct the client to wear a mask at work
Answer: c. refer coworkers who might have been exposed to a provider for prophylactic
antibiotics
Rationale:
In the event of a potential anthrax exposure, referring coworkers who might have been exposed
to a healthcare provider for prophylactic antibiotics is a proactive measure to prevent the
development of anthrax infection. Alerting family members, placing the employee under
quarantine, and instructing the client to wear a mask are not appropriate actions for anthrax
exposure.
14. a community health nurse is providing teaching to a group of clients who have alcohol use
disorder. which of the following findings should the nurse include in the teaching as a
manifestation of alcohol withdrawal?
a. bradycardia
b. hypothermia
c. increased appetite
d. insomnia
Answer: d. Insomnia
Rationale:
Insomnia is a common symptom of alcohol withdrawal, along with other symptoms such as
anxiety, tremors, sweating, and nausea. Bradycardia (slow heart rate), hypothermia, and
increased appetite are not typically associated with alcohol withdrawal.
15. a nurse is caring for a client who is homeless. which of the following actions should the nurse
take first?
a. determine the clients understanding of her living situation
b. assist the client to develop goals for obtaining shelter
c. discuss the risks of being homeless with the client
d. develop client teaching using a variety of strategies
Answer: a. determine the clients understanding of her living situation
Rationale:
Understanding the client's perception of her living situation is crucial to providing effective care
and support. This information can help the nurse assess the client's needs and priorities, which
can guide further interventions such as assisting the client in developing goals for obtaining
shelter, discussing the risks of homelessness, and providing client teaching.
16. a community health nurse observes the accumulation of garbage at a neighborhood
playground. which of the following actions should the nurse take first to promote a clean and
safe environment?
a. meet with community members to discuss methods of playground maintenance
b. partner city officials with community members to improve the playground condition
c. work with local businesses to sponsor more trash receptacles in the playground
d. engage neighborhood families to monitor the playground for further trash buildup
Answer: a. meet with community members to discuss methods of playground maintenance
Rationale:
Engaging with community members to discuss methods of playground maintenance allows for
collaborative problem-solving and community involvement in finding a solution to the issue.
Partnering with city officials, working with local businesses to sponsor trash receptacles, and
engaging neighborhood families to monitor the playground can be effective actions but may
come after discussing maintenance methods with the community.
17. a nurse in a mobile health clinic is caring for a client who requires a tetanus immunization
and is accompanied by his daughter. the client does not speak the same language as the nurse.
which of the following actions should the nurse take?
a. have the client’s daughter communicate information about the procedure
b. arrange for a member of the client’s community to interpret the teaching
c. identify the clients spoken dialect prior to contacting an interpreter
d. use professional terminology when providing education prior to the procedure
Answer: c. identify the clients spoken dialect prior to contacting an interpreter
Rationale:
Identifying the client's spoken dialect is important to ensure effective communication with an
interpreter. This allows for the selection of an interpreter who can accurately convey information
in the client's language, enhancing understanding and compliance. Using the client's daughter or
professional terminology without proper interpretation may lead to misunderstandings.
18. a nurse at a local health department is caring for several clients. which of the following
infections should the nurse report to the state health department?
a. chlamydia
b. herpes simplex virus
c. group B Streptococcus B hemolytic
d. human papillorna virus
Answer: a. Chlamydia
Rationale:
Chlamydia is a reportable sexually transmitted infection (STI) in most states. Reporting of
chlamydia cases to the state health department is required for surveillance and public health
monitoring. Herpes simplex virus, group B Streptococcus B hemolytic, and human
papillomavirus are not typically reportable infections.
19. a clinic nurse is assessing a client who has measles. which of the following findings should
the nurse expect?
a. koplik spots inside the mouth
b. persistent low grade temperature
c. muscle aches and tenderness
d. rash confined to the trunk of the body
Answer: a. koplik spots inside the mouth
Rationale:
Koplik spots are small white spots that appear on the inside of the mouth and are characteristic of
measles. They are an early sign of the disease and typically appear before the measles rash
develops. Persistent low-grade fever, muscle aches and tenderness, and a rash confined to the
trunk of the body are also associated with measles, but koplik spots are specific to this disease.
20. a community health nurse is planning a program for adolescents about preventing STIs.
which of the following actions should the nurse take first?
a. collect data to identify barriers to learning
b. establish methods to evaluate program outcomes
c. obtain visual aids that feature adolescents
d. provide computer based education
Answer: a. collect data to identify barriers to learning
Rationale:
Before planning the program, the nurse should collect data to identify barriers to learning among
the target population. This information will help the nurse tailor the program to address the
specific needs and challenges faced by adolescents in preventing STIs.
21. a nurse is counseling a client who has a new diagnosis of chlamydia. which of the following
information should the nurse include in the teaching? (select all that apply)
a. you should avoid sexual contact until therapy is complete
b. notify anyone with whom you have had sexual contact over the past 2 months
c. you will need to take an antiviral medication for 30 days
d. once your complete treatment you will have an acquired immunity against chlamydia
e. you might experience painful urination until the infection has resolved
Answer: a. you should avoid sexual contact until therapy is complete
b. notify anyone with whom you have had sexual contact over the past 2 months
e. you might experience painful urination until the infection has resolved
Rationale:
a. The client should avoid sexual contact until therapy is complete to prevent the spread of the
infection to others.
b. Notifying anyone with whom the client has had sexual contact over the past 2 months is
important so that they can seek testing and treatment if necessary.
e. Painful urination is a common symptom of chlamydia and the client should be informed that
this symptom may persist until the infection has resolved.
22. a home health nurse is planning the initial home visit for a client who has dementia and lives
with his adult son’s family. which of the following actions should the nurse take first during the
visit?
a. encourage the family to join a support group
b. provide the family with information about respite care
c. educate the family regarding the progression of dementia
d. engage the family in informal conversation
Answer: d. engage the family in informal conversation
Rationale:
Engaging the family in informal conversation helps establish rapport and gather information
about the client's living situation, routines, and any immediate concerns. This information will
guide the nurse in assessing the client's needs and developing a comprehensive care plan.
23. a parrish nurse is counseling a family following a client’s recent diagnosis of heart disease.
which of the following actions should the nurse take first?
a. discuss the benefits of eating a well-balanced diet with the client’s family
b. assist the client and the clients partner with finding an affordable exercise program
c. offer to accompany the client and the clients partner during health care provider visits
d. ask family members about the impact of the disease on relationships within the family
Answer: d. ask family members about the impact of the disease on relationships within the
family
Rationale:
The nurse should first assess the impact of the disease on relationships within the family to
understand the family dynamics and potential stressors. This information will help the nurse
provide appropriate support and interventions to address the family's needs.
24. a nurse is caring for a client who is having difficulty performing activities of daily living. the
nurse is functioning in which of the following roles when arranging for an occupational therapist
to visit the client.
a. Administrator
b. nurse consultant
c. case manager
d. clinician
Answer: c. case manager
Rationale:
As a case manager, the nurse is responsible for coordinating the client's care and arranging for
services, such as occupational therapy, to meet the client's needs. The nurse acts as a liaison
between the client, the healthcare team, and other service providers to ensure comprehensive
care.
25. a nurse is working in a shelter following a disaster. which of the following is the priority
action for the nurse to take?
a. create diversionary activities for children
b. address the physical needs of clients
c. help clients gather needed supplies
d. explore feelings the clients are experiencing
Answer: b. address the physical needs of clients
Rationale:
In a disaster situation, addressing the physical needs of clients, such as providing food, water,
shelter, and medical care, is the priority. This ensures the safety and well-being of the individuals
affected by the disaster.
26. a community health nurse is planning a smoking cessation class. which of the following
factors will have the greatest effect on the success of the class?
a. presenters teaching strategies
b. presenter’s credibility
c. client’s motivation
d. client’s education level
Answer: c. client’s motivation
Rationale:
Client motivation is the most influential factor in the success of a smoking cessation class.
Motivated clients are more likely to actively engage in the program, adhere to the strategies
taught, and ultimately succeed in quitting smoking.
27. a home health nurse is caring for a client who has chemotherapy induced nausea that has
been resistant to relief form pharmacological measures. which of the following interventions
should the nurse initiate (select all that apply)?
a. use seasonings to enhance the flavor of foods
b. provide sips of room temperature ginger ale between meals
c. maintain the head of the clients bed in an elevated position after eating
d. offer 120 ml (4 oz.) of cold 2% milk as a meal replacement
e. assist the client in using guided imagery
Answer: b. provide sips of room temperature ginger ale between meals
c. maintain the head of the clients bed in an elevated position after eating
Rationale:
b. Ginger ale has been shown to help alleviate nausea, especially when served at room
temperature.
c. Keeping the head of the bed elevated after eating can help prevent reflux and reduce nausea.
28. a nurse is preparing an educational program about breastfeeding for a group of new parents.
the nurse should use which of the following instructional strategies to promote psychomotor
learning
a. review flashcards that identify holding technique with the group
b. show the group a video on breastfeeding techniques
c. facilitate a discussion group about the benefits of breastfeeding
d. provide dolls for the participants to demonstrate positioning
Answer: d. provide dolls for the participants to demonstrate positioning
Rationale:
Providing dolls for participants to practice breastfeeding positions allows for hands-on learning
and promotes psychomotor skills development, which is essential for mastering breastfeeding
techniques.
29. a nurse is serving on a state task force for disaster planning. the nurse is engaging in disaster
preparedness efforts when performing which of the following actions
a. implementing a disaster triage plan with a local medical facility
b. functioning as a manager at a temporary shelter
c. assisting with the identification of a biological agent
d. organizing a mass casualty drill for community members
Answer: d. organizing a mass casualty drill for community members
Rationale:
Organizing a mass casualty drill for community members is a proactive approach to disaster
preparedness. It helps assess the community's readiness and response capabilities in the event of
a disaster, allowing for improvements and adjustments to be made to the disaster response plan.
30. a 35-year-old client who has a diagnosis of tuberculosis informs the providers office that she
is unable to pay for the treatment. which of the following actions by the nurse will facilitate
obtaining appropriate treatment?
a. help the client apply for Medicare
b. explore options for alternative therapies
c. arrange for medication through local agencies
d. send the client to the nearest facility for further evaluation
Answer: c. arrange for medication through local agencies
Rationale:
Arranging for medication through local agencies, such as public health departments or
tuberculosis control programs, can help the client access treatment even if they are unable to pay
for it. These agencies often have resources available to provide medications at reduced or no
cost.
31. a public health nurse is addressing community leaders at a forum about community
improvement. the nurse should identify which of the following groups as being the fastest
growing segment of the homeless population.
a. people who have substance use disorders
b. families who have children
c. adolescent runaways
d. men who are unemployed
Answer: b. families who have children
Rationale:
Families who have children are the fastest-growing segment of the homeless population. This
group faces unique challenges and requires specific interventions and support services to address
their needs.
32. a nurse is counseling a client who is to undergo enzyme linked immunosorbent assay testing
for hiv. which of the following information should the nurse include?
a. the test monitors progression of the disease
b. the test measures antibodies to the virus
c. the test results are accurate 24 hr. after exposure to the virus
d. a positive result requires initiating immunoglobulin administration
Answer: b. the test measures antibodies to the virus
Rationale:
Enzyme-linked immunosorbent assay (ELISA) testing for HIV detects antibodies to the virus,
not the virus itself. It is used to determine if a person has been infected with HIV by detecting the
presence of these antibodies in the blood.
33. a nurse case manager is providing discharge planning for a client. the nurse is functioning in
which of the following roles when arranging for the delivery of medical equipment to the client’s
home
a. consultant
b. systems allocator
c. advocate
d. coordinator
Answer: c. advocate
Rationale:
In this situation, the nurse is advocating for the client by ensuring that the necessary medical
equipment is delivered to the client's home. Advocacy involves supporting and promoting the
client's best interests and ensuring they receive appropriate care and services.
34. a faith based organization asks a community health nurse to develop a mobile meal program
for older the following actions should the nurse plan to take first.
a. determine potential funding sources for the program
b. inquire about the availability of volunteers
c. identify alternative solutions to address concerns
d. perform a needs assessment
Answer: d. perform a needs assessment
Rationale:
Before developing a mobile meal program, the nurse should first perform a needs assessment to
determine the specific needs and preferences of the older adults in the community. This
information will guide the development and implementation of the program to ensure it meets
the needs of the target population.
35. several nurses are developing a parish nurse group to help address the primary and secondary
health care needs of the congregation. which of the following services should the nurses plan to
provide to the congregation?
a. organize an influenza immunization clinic with the American red cross
b. perform wound care in the home of members
c. provide end of life care for members who are terminal
d. facilitate discharge from the facility to the home
Answer: a. organize an influenza immunization clinic with the American red cross
Rationale:
Organizing an influenza immunization clinic with the American Red Cross helps promote
preventive health measures within the congregation, particularly for a common seasonal illness.
This service aligns with the goals of primary and secondary health care by preventing illness and
promoting early intervention.
36. a community health nurse is caring for client in a culturally diverse community. which of the
following actions demonstrates accurate cultural knowledge about a specific cultural group?
a. touching the hair of an African American client during an assessment
b. offering to shake hands when meeting an Asian client of the opposite gender
c. maintaining eye contact when interviewing a native American client
d. including both hot and cold food items on a Hispanic client’s menu
Answer: d. including both hot and cold food items on a Hispanic client’s menu
Rationale:
Including both hot and cold food items on a Hispanic client's menu demonstrates cultural
knowledge and sensitivity. In many Hispanic cultures, meals are traditionally balanced with both
hot and cold items. This action shows respect for the client's cultural preferences and dietary
habits.
37. a community health nurse is providing screening for lipid disorders. which of the following is
the primary goal of this activity?
a. early detection of disease
b. client enrollment in prevention programs
c. promotion of appropriate lifestyle changes
d. identification of family history of medical problems
Answer: a. early detection of disease
Rationale:
The primary goal of screening for lipid disorders is the early detection of disease. Early detection
allows for timely intervention and management, which can prevent the progression of the
disorder and reduce the risk of complications.
38. a school nurse is implementing health screening. which of the following assessment finding
should the nurse recognize as the highest priority?
a. a child who has a BMI of 18
b. an adolescent who has scoliosis
c. an adolescent who has psoriasis
d. a child who has nits
Answer: d. a child who has nits
Rationale:
The presence of nits (lice eggs) indicates an active infestation, which can easily spread to other
children. Immediate intervention is necessary to prevent further transmission within the school
setting.
39. which of the following should the nurse include
a. should be placed beside the child’s bed
b. house hold contacts will receive prophylactic antibiotics
c. transmission will be emitted because of herd immunity
d. the child is most contagious after the rash develops
Answer: b. house hold contacts will receive prophylactic antibiotics
Rationale:
In cases of certain contagious diseases, such as bacterial meningitis, household contacts may
receive prophylactic antibiotics to prevent the spread of the disease. This measure is important
for controlling outbreaks and protecting vulnerable individuals.
40. a home health nurse is scheduled for a first time visit to a client. which of the following
should the nurse perform first?
a. blood pressure screening
b. mental status examination
c. review of the neighborhood
d. family history
Answer: b. mental status examination
Rationale:
Performing a mental status examination first allows the nurse to assess the client's cognitive
function and orientation. This information is crucial for determining the client's overall health
status and identifying any immediate concerns that may require intervention.
41. in the last month three cases of tuberculosis have been referred to the health department.
which of the following is the priority information for the community health nurse to obtain from
each client?
a. demographics
b. house hold members
c. occupation
d. health history
Answer: b. house hold members
Rationale:
Obtaining information about household members is crucial in tuberculosis (TB) cases to assess
the risk of transmission within the household. Close contacts of individuals with TB are at higher
risk of infection and may require testing and treatment.
42. a nurse is working to reduce individual and family violence in the local community. which of
the following actions by the nurse demonstrates a primary prevention strategy to achieve this
goal?
a. conducting counseling for at risk parents
b. assessing a family for marital discord
c. teaching parenting techniques to new parents
d. providing treatment for a young adult who has a substance use disorder
Answer: c. teaching parenting techniques to new parents
Rationale:
Teaching parenting techniques to new parents is a primary prevention strategy aimed at reducing
individual and family violence by providing parents with the skills and knowledge to prevent
abusive behaviors before they occur.
43. a newly hired occupational health nurse is assessing hazards in the work environment. which
of the following actions will help the nurse detect potential physical hazards?
a. track rates of illness caused by infection among employees
b. survey workers about job related emotional stress
c. identify industrial toxins that are present in the environment
d. measure noise levels at various locations in the facility
Answer: d. measure noise levels at various locations in the facility
Rationale:
Measuring noise levels at various locations in the facility can help the nurse detect potential
physical hazards related to excessive noise exposure, which can lead to hearing loss and other
health issues.
44. a school nurse is planning safety education for a group of adolescents. the nurse should give
priority to which of the following topics as the leading cause of death for this age group
a. motor vehicle safety
b. sports injury prevention
c. substance abuse prevention
d. gun safety
Answer: a. motor vehicle safety
Rationale:
Motor vehicle crashes are the leading cause of death among adolescents. Educating adolescents
about motor vehicle safety, including seat belt use, avoiding distractions while driving, and the
dangers of impaired driving, is crucial for injury prevention.
45. a nurse of a community clinic is preparing an educational guide about cultural variances in
expression of pain. which of the following information should the nurse include?
a. middle eastern cultural practices include hiding pain from close family members
b. native American cultural practices include being outspoken about pain
c. Puer to Rican cultural practices include the view that outspoken expressions of pain are
shameful
d. Chinese cultural practices include enduring pain to prevent family dishonor
Answer: d. Chinese cultural practices include enduring pain to prevent family dishonor
Rationale:
Including information about cultural variances in the expression of pain is important for
providing culturally sensitive care. Understanding that Chinese cultural practices may include
enduring pain to prevent family dishonor can help healthcare providers tailor their approach to
pain management for clients from this cultural background.
46. the partner of an older adult client who has Alzheimer’s disease reports that he is not eating.
the nurse client partner refuses to assist the client with feeding. the partner insists the client feed
himself without help. which of the priority action the nurse should take?
a. arrange for meals on wheels’ assistance
b. determine the client’s ability to self-feed
c. direct the home health aide to assist with meals
d. refer the clients partner to an Alzheimer’s support group
Answer: b. determine the client’s ability to self-feed
Rationale:
The priority action is to determine the client's ability to self-feed. This assessment will help the
nurse understand the client's current capabilities and limitations related to feeding and guide
further interventions and assistance as needed.
47. a nurse is planning priority
a. encourage enrollment and attendance at weight reduction programs
b. educate children at a day care center about nutrition and exercise
c. distribute health risk appraisal questionnaires at community functions
d. measure the BMI of older adults at a community senior center
Answer: b. educate children at a day care center about nutrition and exercise
Rationale:
Education about nutrition and exercise for children at a day care center is a priority because it
can help establish healthy habits early in life, which can have long-term benefits for their health.
48. a nurse working in an infectious disease clinic is caring for a client has a new diagnosis of
Lyme disease. which of the following agencies is responsible for voluntarily reporting cases of
this disease to the centers for disease control and prevention
a. office of the surgeon general
b. state health department
c. hospital infection control department
d. local red cross chapter
Answer: b. state health department
Rationale:
The state health department is responsible for voluntarily reporting cases of Lyme disease to the
Centers for Disease Control and Prevention (CDC) as part of the national surveillance system for
tracking and monitoring infectious diseases.
49. a nurse is providing teaching to a 50-year-old female client. which of the following
statements should the nurse include in the teaching?
a. you should have a complete eye examination every 2 years until the age of 64
b. you should have your hearing screened every 5 years
c. you should have your stool tested for blood every other year until the age of 74
d. you should have your fasting blood glucose level checked every 6 years
Answer: c. you should have your stool tested for blood every other year until the age of 74
Rationale:
Stool testing for blood is recommended every other year until the age of 74 as part of colorectal
cancer screening guidelines for adults aged 50 and older. This screening can help detect
colorectal cancer early when treatment is most effective.
50. a nurse is discussing short and long term goals with a client who has alcohol use disorder and
is being admitted to a treatment facility. which of the following statements is appropriate for the
nurse to include in the discussion?
a. you will be taking a once weekly dose of disulfiram to help control withdrawal symptoms
during treatment
b. remaining physically active will help to minimize drowsiness and chills associated with initial
alcohol withdrawal.
c. attending Al anon meetings will help you identify a role model to assist you with making
needed changes
d. you will begin learning functional skills to replace defense mechanisms and behaviors while in
treatment
Answer: c. attending Al anon meetings will help you identify a role model to assist you with
making needed changes
Rationale:
Attending Al-Anon meetings can provide support and guidance from others who have
experienced similar challenges with alcohol use disorder. It can also help the client identify
positive role models and strategies for making necessary changes.
51. a nurse is assessing an outbreak of mumps among school age children. using the
epidemiological triangle. the nurse should recognize that which of the following is the host.
a. the vaccine
b. the virus
c. the school
d. the children
Answer: d. the children
Rationale:
In the epidemiological triangle, the host is the organism (in this case, the children) that provides
the environment for the infectious agent (the virus) to live and reproduce.
52. a community health nurse is working with a group of homeless veterans who have
posttraumatic stress disorder. which of the following interventions should the nurse implement?
a. provide coffee and snacks during the meetings
b. avoid discussing the traumatic events experienced by the veterans
c. change the meetings sites frequently
d. teach the clients to practice deep breathing exercises
Answer: d. teach the clients to practice deep breathing exercises
Rationale:
Teaching deep breathing exercises can help individuals with posttraumatic stress disorder
(PTSD) manage symptoms of anxiety and stress. This intervention can provide a coping
mechanism for the veterans to use in challenging situations.
53. client states my life has no meaning right now.
a. have you been thinking about harming yourself
b. how long have you been feeling this way
c. tell me what is going on with you right now
d. do you really think your life has no purpose
Answer: a. have you been thinking about harming yourself
Rationale:
This question assesses the client's risk of self-harm or suicide, which is crucial when a client
expresses feelings of hopelessness or meaninglessness.
54. a nurse is providing education to a group of adolescents who are pregnant and attending high
school. which of the following information should the nurse include in their teaching?
a. the need for supplemental folic acid is greatest during the third trimester
b. the incidence of high birth weight infants is higher in adolescent pregnancy
c. pregnant adolescent need to gain less weight than adult mothers
d. caffeinated beverages should be replaced with caffeine-free beverages
Answer: d. caffeinated beverages should be replaced with caffeine-free beverages
Rationale:
Pregnant adolescents should avoid or limit caffeine intake, so it's important to educate them
about replacing caffeinated beverages with caffeine-free options for a healthier pregnancy.
55. nurse expect
a. oliguria
b. diplopia
c. hypoglycemia
d. dizziness
Answer: a. oliguria
Rationale:
Oliguria, or decreased urine output, is a common symptom of acute renal failure, which can
occur as a complication of conditions like shock or severe dehydration.
56. a community health clinic nurse manager is reviewing the incidence rate of chlamydia in the
state. in a given year, 3144 new cases were reported and the population was estimated at
325,986. which of the following is the incidence rate in the state for the year?
a. about 300 reported cases per 100,000 population
b. about 1 reported case per 10,000 population
c. about 10 reported cases per 1000 population
d. about 3 reported cases per 10,000 population
Answer: c. about 10 reported cases per 1000 population
Rationale:
Incidence rate is calculated as the number of new cases divided by the total population at risk,
multiplied by a multiplier (usually 1000 or 100,000) to express the rate per unit of population. In
this case, it's about 10 reported cases per 1000 population.
57. a home health nurse is visiting a client who had a stroke 2 months ago. which of the
following findings should the nurse report to the interprofessional care team?
a. the client dresses her affected side first.
b. the client bears weight on their arms when using crutches
c. the client coughs when swallowing her medications
d. the client’s caregiver fills a pill organizer weekly
Answer: c. the client coughs when swallowing her medications
Rationale:
Coughing when swallowing medications can be a sign of dysphagia, which is common after a
stroke and can lead to aspiration pneumonia. It should be reported to the interprofessional care
team for further evaluation and management.
