During a community health screening fair for older adults, the nurse observes a client who has pale, bluish feet, with sores an both lower extremities that are healing poorly. Which intervention should the nurse implement?

Refer to healthcare provider for complete evaluation.

Send client to the emergency department for treatment.

Instruct client to apply antibiotic ointment to sores.

Create a list of foods that promote wound healing.

Answer and Explanation

The Correct Answer is A

A) Refer to healthcare provider for complete evaluation:
The symptoms described—pale, bluish feet, and sores with poor healing—are indicative of possible peripheral vascular disease, circulatory issues, or other serious conditions that require a thorough medical evaluation. Referring the client to a healthcare provider ensures that a comprehensive assessment can be performed to diagnose the underlying cause and develop an appropriate treatment plan.

B) Send client to the emergency department for treatment:
While the symptoms are concerning, they do not necessarily indicate an immediate emergency requiring urgent care. Referral to a healthcare provider for a complete evaluation is generally more appropriate unless the client exhibits signs of a life-threatening condition or severe infection.

C) Instruct client to apply antibiotic ointment to sores:
Applying antibiotic ointment might help with wound care but does not address the underlying issue that is causing the poor wound healing and the bluish discoloration. Without a complete evaluation, it's uncertain whether antibiotic ointment alone will be sufficient or appropriate.

D) Create a list of foods that promote wound healing:
Although nutrition is important for wound healing, addressing the underlying health issues affecting the client's circulation and skin integrity is more critical. A healthcare provider can offer comprehensive treatment that includes managing the client’s overall health condition, which may involve more than just dietary changes.

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Correct Answer is D

Explanation

A) Review the home medication schedule with the client and family:
While reviewing the home medication schedule is an important step in ensuring that the client understands their medications, it is not the immediate priority when considering the client's safety at home. The primary concern should be addressing the client’s ability to safely navigate their home environment.

B) Provide the client with information about medical alert devices:
Providing information about medical alert devices is valuable for enhancing the client’s safety. However, it should come after addressing the more immediate concern of assessing the home environment for safety issues. The client’s current ability to walk and potential home hazards need to be evaluated first.

C) Arrange for a bedside commode to be delivered to the home:
While a bedside commode can be helpful for the client’s convenience and safety, it is not the most critical action to address immediately. Ensuring that the overall home environment is safe and suitable for the client’s needs should take precedence.

D) Meet with the case manager to plan a home safety evaluation:
Meeting with the case manager to arrange a home safety evaluation is the most crucial initial step. A home safety evaluation will identify potential hazards and ensure that the living environment is adapted to the client’s needs, which is essential for preventing falls and other accidents. This assessment will help in planning for appropriate modifications and support services to ensure the client’s safety at home.

A. Contact kindergarten parents to remind them that the second dose of MMR is due at the start of the school year. B. Send notices home with the children on the first day of class advising that MMR vaccine series must be completed. C. Note in student records that the second dose of the MMR vaccine should be administered prior to entering first grade. D. Speak at the next parent-teacher association meeting to teach parents the benefits of immunizing their children.

Correct Answer is A

Explanation

A) Contact kindergarten parents to remind them that the second dose of MMR is due at the start of the school year:
Directly contacting parents before the school year begins is the most effective intervention for ensuring that students receive the necessary immunizations. By reminding parents ahead of time, the school nurse can help ensure that the second dose of the MMR vaccine is administered before the start of kindergarten, which is crucial for meeting school entry requirements and protecting public health.

B) Send notices home with the children on the first day of class advising that MMR vaccine series must be completed:
Sending notices on the first day of class might be too late for many parents to act on promptly. Ensuring that children have received the second dose of the MMR vaccine before the school year starts is important for compliance and preventing potential outbreaks.

C) Note in student records that the second dose of the MMR vaccine should be administered prior to entering first grade:
While noting the requirement in student records is important for long-term tracking, it does not address the immediate need to ensure that students are up-to-date with their vaccinations before starting kindergarten. Immediate action is necessary to ensure compliance at the beginning of the school year.

D) Speak at the next parent-teacher association meeting to teach parents the benefits of immunizing their children:
While educating parents about the benefits of immunization is valuable, it does not directly address the immediate need for the second dose of the MMR vaccine. Direct reminders and actions to ensure vaccinations are up-to-date are more effective in achieving timely compliance.

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During a community health screening fair for older adults, the nurse observes a client who has pale, bluish feet, with sores an both lower extremities that are healing poorly. Which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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