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 C

Explanation

A. Characteristics of families in the upper-middle class:
Understanding the characteristics of families in a specific income bracket can provide useful context, but it does not directly address the distribution of income within the community. The focus should be on the entire income range and how it affects the community's needs.

B. The reliability of such a high average family income:
While it's important to consider the accuracy of data, this question is more about how the range and distribution of income affect the community. The reliability of the data is less relevant than understanding the income distribution.

C. The frequency of incomes above and below the average:
Assessing the frequency of incomes above and below the average provides a better understanding of income distribution within the community. This information helps identify socioeconomic disparities and guide targeted interventions or resources needed for different income groups.

D. Interventions focused on college-educated individuals:
Focusing on college-educated individuals may be relevant in some contexts, but it does not address the broader issue of income distribution. Understanding the frequency of different income levels is more directly related to addressing the needs of the community based on their income range.

A. Smoking cessation. B. Compliance with antihypertensive and lipid lowering agents. C. Blood pressure and lipid screening. D. Increase physical activity and diet low in saturated fat.

Correct Answer is C

Explanation

A) Smoking cessation:
Smoking cessation is a crucial preventive measure and is considered a primary prevention strategy to reduce the risk of developing smoking-related diseases. However, for a middle-aged client who already has health issues such as obesity or hypertension, secondary prevention focuses on early detection and management of conditions that have already developed or are at high risk of developing.

B) Compliance with antihypertensive and lipid-lowering agents:
While compliance with medication is essential for managing existing conditions such as hypertension or dyslipidemia, it is not a secondary prevention measure in itself. Secondary prevention is focused on screening and early detection of health issues before they progress further.

C) Blood pressure and lipid screening:
Blood pressure and lipid screening are appropriate secondary prevention measures for this client. Secondary prevention involves identifying and managing health conditions early to prevent progression or complications. Given the client’s smoking history, weight, and potential risk for cardiovascular issues, regular screening for blood pressure and lipid levels helps detect any developing issues early, allowing for timely intervention.

D) Increase physical activity and diet low in saturated fat:
Increasing physical activity and adopting a diet low in saturated fat are important lifestyle changes for overall health and primary prevention of chronic diseases. However, in the context of secondary prevention, where the focus is on monitoring and managing existing risk factors or health conditions, screening measures like blood pressure and lipid testing are more directly relevant.

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Naxlex Comprehensive Predictor Exams

The community health nurse determines that the average family income of a certain community is $67,000 per year with a range of $27,000 to $102,000. Based on this demographic information, which additional information is important for the nurse to assess?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

The nurse notes that the influenza immunization rates are much lower for certain demographic groups than for others. Which intervention is likely to be most useful in increasing the rates of immunization in these under-served immunization groups?

The nurse is teaching adults in the community about suicide awareness. Which information should the nurse include in the teaching?

On a day when the temperature is expected to drop to below freezing during the night, the nurse is asked to determine which homeless adults are most in need of the limited spaces that are available in a shelter. It is most important for which person to be admitted for the night?

Several clients who have recently come to the local health clinic in a rural county are diagnosed with tuberculosis (TB). After reporting the occurrence to the health department, which community focused action should the nurse implement first?

One hundred families in a community refuse to have their children immunized because of religious beliefs. When one documented case of whooping cough occurs within this aggregate, which intervention should the nurse implement?

The city health department director asks the community health nurse to make a presentation describing the greatest health concern facing the city. How should the nurse begin to collect the data needed for this presentation?

A community health nurse is planning strategies to prevent an increase in the incidence of osteoporosis in the community. Which activity should the nurse include?