During a community health screening fair for older adults, a nurse notices a client with pale, bluish feet and sores on both lower extremities that are healing poorly.
What should the nurse’s intervention be?

Instruct the client to apply antibiotic ointment to the sores.

Create a list of foods that promote wound healing.

Refer the client to a healthcare provider for a complete evaluation.

Send the client to the emergency department for treatment.

Answer and Explanation

The Correct Answer is C

Answer and explanation The correct answer is C. Choice A rationale

While applying antibiotic ointment to the sores might help prevent infection, it does not address the underlying issue causing the sores and poor healing.

Choice B rationale

Although a diet rich in nutrients can promote wound healing, it is not the most immediate need for this client. The client’s symptoms suggest a serious underlying condition that requires medical evaluation.

Choice C rationale

The client’s symptoms of pale, bluish feet and sores on both lower extremities that are healing poorly suggest a severe and untreated medical condition, possibly related to circulation or skin integrity. Therefore, the nurse should refer the client to a healthcare provider for a complete evaluation.

Choice D rationale

Sending the client to the emergency department for treatment might be necessary in some cases, but it is more appropriate to first refer the client to a healthcare provider for a complete evaluation.

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Correct Answer is B

Explanation

Answer and explanation

The correct answer is Choice B.

Choice A rationale

Rechecking the client’s vital signs in 30 minutes may not be the most appropriate action in this situation. The client is showing signs of possible complications such as infection (elevated

temperature, malaise) and referred pain in the shoulder, which could indicate diaphragmatic irritation. These symptoms, along with the client’s recent surgery, suggest that immediate medical attention may be necessary.

Choice B rationale

Having the client transported via ambulance to the hospital is the most appropriate action. The client’s symptoms suggest possible complications that require immediate medical attention.

Abdominal tenderness and shoulder pain could indicate a serious condition such as a perforation or infection. The elevated heart rate and low blood pressure could suggest sepsis or shock. Immediate medical evaluation and treatment are necessary.

Choice C rationale

Determining the client’s current oxygen saturation rate is important, but it is not the most immediate need. While this information could provide additional data about the client’s condition, it does not address the potential seriousness of the client’s symptoms. The client needs immediate medical attention.

Choice D rationale

Instructing the client to drive to the hospital for admission is not the best choice. Given the client’s symptoms and recent surgery, it would be safer for the client to be transported by ambulance. This would ensure that the client receives immediate medical attention and that the client’s condition can be monitored during transport.

A. Perceived barriers. B. Perceived susceptibility. C. Perceived severity. D. Perceived benefits.

Correct Answer is B

Explanation

The correct answer is B. Perceived susceptibility.

Explanation:

The Health Belief Model (HBM) explains health-related behaviors based on an individual's perceptions. Perceived susceptibility refers to a person's belief about their risk of developing a disease. In this case, the client believes they are not susceptible to the flu, which influences their decision not to get vaccinated.

Why the other options are incorrect:

A. Perceived barriers – This refers to obstacles preventing someone from taking action, such as cost or fear of side effects. The client did not mention barriers, only their belief that they don’t get the flu.
C. Perceived severity – This relates to how serious a person believes a condition is. The client did not indicate concern about how severe the flu might be, only that they don’t expect to get it.
D. Perceived benefits – This focuses on a person’s belief in the effectiveness of an action. The client’s response does not express doubts about the vaccine’s benefits, just their belief that flu prevention is unnecessary for them.

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During a community health screening fair for older adults, a nurse notices a client with pale, bluish feet and sores on both lower extremities that are healing poorly.What should the nurse’s intervention be?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A client comes to the clinic for an annual physical exam. When asked about their influenza vaccine status, the client responds, “I never get the vaccine because I don’t get the flu.”. Which aspect of the Health Belief Model is the client demonstrating?

Correct Answer is B

Explanation

Explanation:

Why the other options are incorrect:

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During a community health screening fair for older adults, a nurse notices a client with pale, bluish feet and sores on both lower extremities that are healing poorly.
What should the nurse’s intervention be?