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) Long bone density testing:
Bone density testing is typically not a priority for elementary school students. This type of testing is more relevant for older populations or individuals at risk for conditions such as osteoporosis. For elementary-aged children, other measures are more pertinent to their immediate health needs.

B) Annual flu vaccination status:
While tracking annual flu vaccination status is important for preventing influenza and maintaining public health, it does not encompass a broad range of health risks. A health risk screening protocol should include measures that provide a comprehensive view of a child's overall health and growth.

C) Weight and height measurement:
Weight and height measurements are fundamental components of health risk screening in elementary school children. These measurements help assess growth patterns, identify potential issues with malnutrition or obesity, and monitor overall health. They are critical for evaluating whether children are developing appropriately and for identifying early signs of potential health problems.

D) Serum total cholesterol level:
Measuring serum total cholesterol levels is more relevant for older children or those with specific risk factors for cardiovascular disease. For elementary school children, it is more practical to focus on growth metrics such as weight and height, which provide immediate and actionable insights into their health status.

A. 3/1,000. B. 30/1,000. C. 1.7/1,000. D. 15/1,000.

Correct Answer is B

Explanation

A) 3/1,000:
To calculate the rate per 1,000, you divide the number of new positive tests by the total number of students tested, then multiply by 1,000. For 15 new positive tests among 500 students, the rate is (15/500) * 1,000 = 30/1,000. Thus, 3/1,000 is incorrect.

B) 30/1,000:
The correct calculation for the rate per 1,000 is determined by dividing the number of new positive tests (15) by the total number of students tested (500) and then multiplying by 1,000. Therefore, (15/500) * 1,000 = 30/1,000. This rate accurately reflects the proportion of students with positive tests per 1,000.

C) 1.7/1,000:
The rate of 1.7/1,000 would result from incorrect calculations. Using the correct formula, the rate per 1,000 should be 30/1,000.

D) 15/1,000:
The rate of 15/1,000 suggests that there are 15 positive tests per 1,000 students, which does not reflect the actual number of new positive tests (15) among 500 students. The correct rate calculation yields 30/1,000, not 15/1,000.

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Naxlex Comprehensive Predictor Exams

A school nurse is developing a health risk screening protocol for use at an elementary school. Which information is most important for the nurse to include in this protocol?

Correct Answer is C

Explanation

A school nurse identifies 15 new students with positive tuberculin tests among the 500 at-risk students fested. Which is the rate per 1,000 with new positive tests?

Correct Answer is B

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?

The community health nurse believes that immunization rates in a lower-socioeconomic section of the city are probably below the target set by the state health department. Which action should the nurse take first to intervene with this health problem?

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?

According to the Centers for Disease Control and Prevention, which diseases are reportable infectious diseases? Select all that apply.

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?

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.)

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?

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?