The home health nurse enters the home of a client, and the client's spouse immediately reports that the client cannot be awakened and appears to have taken an overdose of some medications. After determining that the client is unresponsive but is breathing and has a pulse, which action should the nurse take?

Call 911 for emergency transport.

Determine what medications were ingested.

Contact the poison control center.

Attempt to induce vomiting using a tongue blade.

Answer and Explanation

The Correct Answer is A

A) Call 911 for emergency transport:
The client is unresponsive, which is a critical situation requiring immediate medical attention. Even though the client is breathing and has a pulse, the unresponsiveness suggests a potentially severe overdose that could rapidly deteriorate. Calling 911 ensures that emergency medical services are on their way to provide advanced care and transport to a facility where further treatment can be administered.

B) Determine what medications were ingested:
While knowing what medications were taken is important for treatment, the immediate priority is to address the client’s unresponsiveness. Identifying the medications can be done once the client is stabilized or while awaiting emergency services, but it does not replace the need for urgent medical intervention.

C) Contact the poison control center:
Contacting the poison control center is useful for guidance on managing an overdose, but it should be done in conjunction with calling 911 if the client is unresponsive. The poison control center can provide specific treatment advice, but immediate emergency medical assistance is crucial for the client’s safety.

D) Attempt to induce vomiting using a tongue blade:
Inducing vomiting can be dangerous, especially if the client is unresponsive or has an impaired airway. Attempting to induce vomiting without professional medical support could lead to aspiration or other complications. The priority is to ensure the client receives proper medical care through emergency services.

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Correct Answer is D

Explanation

A) Hepatitis B vaccine:
While Hepatitis B is a significant vaccine for many travelers, especially those at risk of bloodborne pathogen exposure or those planning extended stays, Hepatitis A is more commonly prioritized for short-term travel to developing nations where sanitation and food safety may be compromised.

B) Influenza vaccine:
The influenza vaccine is important for seasonal protection against flu, but it is not specifically targeted at the types of health risks commonly encountered in developing nations. It's generally recommended for annual protection but is not the primary concern for travel to developing countries.

C) Tetanus toxoid vaccine:
Tetanus is a concern for wound management and prevention of tetanus infection, but it is not specific to travel to developing nations. This vaccine is typically part of routine immunizations and might be updated based on injury or specific risk factors, rather than travel alone.

D) Hepatitis A vaccine:
Hepatitis A is crucial for travelers to developing nations because it is transmitted through contaminated food and water. In areas with poor sanitation and hygiene, the risk of Hepatitis A is high. Therefore, the Hepatitis A vaccine should be prioritized to prevent infection in these conditions.

A. Small bruises on the lower extremities. B. A one-inch laceration across center of forehead. C. Refusal to answer simple questions. D. Several dime-sized circular burns on the back.

Correct Answer is D

Explanation

A) Small bruises on the lower extremities:
While bruises should be noted and monitored, small bruises on the lower extremities are relatively common in toddlers due to their active nature and frequent minor falls. They do not immediately indicate abuse unless accompanied by other signs.

B) A one-inch laceration across the center of the forehead:
A laceration, especially if it's recent, should be assessed for proper care and treatment. However, a laceration alone does not necessarily indicate abuse and is less urgent compared to signs of possible abuse such as burns.

C) Refusal to answer simple questions:
A toddler’s reluctance to answer questions might be due to shyness or anxiety related to the visit or the situation. This behavior alone does not indicate an immediate need for intervention unless accompanied by other signs of distress or harm.

D) Several dime-sized circular burns on the back:
Circular burns are a significant concern as they are characteristic of burn injuries that may result from abuse, such as being burned by a hot object or liquid. This finding warrants immediate intervention and further investigation to ensure the child’s safety and well-being.

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Naxlex Comprehensive Predictor Exams

A client comes to the public health clinic requesting information about which immunizations to receive prior to visiting a developing nation. Which immunization should the nurse recommend as a priority for this client?

Correct Answer is D

Explanation

A toddler is brought by a parent to the health department for scheduled immunizations. The toddler clings to the caregiver and cowers when approached. Which assessment warrants immediate intervention by the nurse?

Correct Answer is D

Explanation

Four students come to the school clinic simultaneously, seeking help from the school nurse. In which order of priority should the nurse provide care to these students? (Arrange the client with the highest priority first, on top, and lowest priority last, on bottom.)

Which annual screening should the nurse include when planning an eye health program at a preschool?

The epidemiological triad can be used to frame strategies for the prevention of farm machinery injuries. Which action should the nurse take to focus on the agent?

A nurse designs a series of four weekly classes for clients with type 2 diabetes mellitus. Which information should the nurse use as an outcome evaluation for the classes?

A newly hired school nurse conducts a "windshield" survey of the geographic area served by the school, Which method is best for the nurse to use to objectively validate the findings obtained?

A migrant farm worker who lives in a mobile home with several other workers visits the Migrant Health Care Center. The client reports Increasing episodes of dizziness, headaches, abdominal cramps, and difficulty breathing. Which nursing action has the highest priority?

The school nurse administers methylphenidate to an adolescent with Attention Deficit Hyperactivity Disorder (ADHD). When evaluating the drug's effectiveness, which information is most important for the nurse to review?