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) Obtain a restraining order against the father:
Obtaining a restraining order is a legal action that can be taken to protect the child but is not typically within the scope of the nurse’s immediate responsibilities. This action would involve law enforcement and the legal system rather than being an immediate next step in the healthcare setting. The nurse's role is to report the suspected abuse and ensure that appropriate protective services are involved.

B) Encourage the mother to file a police report:
Encouraging the mother to file a police report is a potential step in addressing the situation, but it should not be the nurse's immediate next action. The nurse's primary responsibility is to ensure that the appropriate child protective services are notified and involved, as they are equipped to handle investigations and interventions in cases of suspected child abuse.

C) Ask the child if his father ever spanks him:
Asking the child about specific forms of discipline, such as spanking, could potentially place the child in a difficult or unsafe position, especially if abuse is suspected. It is not the nurse's role to investigate or interrogate the child directly. Instead, the focus should be on ensuring that the proper authorities are notified to handle the investigation.

D) Refer the family to protective service agencies:
Referring the family to protective service agencies is the most appropriate next step. These agencies are specialized in handling cases of suspected abuse and can provide the necessary intervention and support for the child’s safety and well-being. The nurse's role includes reporting suspected abuse to the appropriate authorities and ensuring that protective services are contacted to investigate and address the situation.

A. Evaluate previous project outcomes. B. Interview community members. C. Project future health care requirements. D. Schedule a community-wide health fair.

Correct Answer is B

Explanation

A) Evaluate previous project outcomes:
Evaluating previous project outcomes provides valuable insights into what has been effective or ineffective in past health promotions. However, this step should come after understanding the current needs of the community. Previous outcomes are more relevant once the nurse has a clear grasp of the community’s current health promotion needs.

B) Interview community members:
Interviewing community members is the most immediate and essential action for assessing the community’s health promotion needs. Direct input from community members helps identify their perceptions, needs, and priorities, which is critical for tailoring relevant and effective health promotion interventions. This step provides a foundational understanding of the community's specific health issues and concerns.

C) Project future health care requirements:
Projecting future health care requirements is important for long-term planning but should be informed by an understanding of current community needs. Before making projections, it is necessary to assess and understand the existing health promotion needs through direct community engagement.

D) Schedule a community-wide health fair:
Scheduling a health fair can be an effective health promotion activity, but it should be based on an understanding of the community's specific needs. Without assessing these needs first, the health fair may not address the most pressing issues or effectively engage the community.

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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 B

Explanation

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