Nursing Elites

1. A community health nurse is conducting a home visit to assess a family's health needs. What is the first step in this process?

• A. Develop a care plan
• B. Conduct a physical examination
• C. Establish rapport with the family
• D. Provide health education

Correct answer: C

Rationale: Establishing rapport with the family is crucial in the initial stages of a home visit. It helps build trust, open communication channels, and allows the nurse to gain insight into the family's health needs and concerns. Developing a care plan (Choice A) comes after the assessment phase, where information is gathered. Conducting a physical examination (Choice B) is a part of the assessment but typically follows establishing rapport. Providing health education (Choice D) is important but usually occurs after the assessment and care planning stages.

2. Which of the following is not classified as an essential health service?

• A. Provision of eye glasses and dentures for the elderly
• B. Maternal and child care
• C. Basic sanitation and prevention and control of locally endemic diseases
• D. Promotion of proper nutrition, adequate supply of safe water, and health education

Correct answer: A

Rationale: The provision of eyeglasses and dentures for the elderly is not classified as an essential health service. Essential health services typically focus on preventive, promotive, curative, and rehabilitative care that address the primary healthcare needs of individuals and communities. Choices B, C, and D are examples of essential health services as they directly contribute to improving and maintaining the health of populations. Maternal and child care, basic sanitation, disease prevention, nutrition promotion, safe water supply, and health education are essential components of public health initiatives.

3. The nurse is teaching a client with cardiac disease about the anatomy and physiology of the heart. Which is the correct pathway of blood flow through the heart?

• A. Right ventricle, left ventricle, right atrium, left atrium
• B. Left ventricle, right ventricle, left atrium, right atrium
• C. Right atrium, right ventricle, left atrium, left ventricle
• D. Right atrium, left atrium, right ventricle, left ventricle

Correct answer: C

Rationale: The correct pathway of blood flow through the heart starts with blood entering the right atrium, moving to the right ventricle, then to the lungs for oxygenation, returning to the left atrium, and finally to the left ventricle before being pumped out to the body. Option A is incorrect as it starts with the ventricles instead of the atria. Option B is incorrect as it has the sequence of ventricles before atria reversed. Option D is incorrect as it has the atria and ventricles mixed up.

4. During the care of a client with Legionnaire's disease, which finding would require the nurse's immediate attention?

• A. Pleuritic pain on inspiration
• B. Dry mucus membranes in the mouth
• C. A decrease in respiratory rate from 34 to 24
• D. Decrease in chest wall expansion

Correct answer: D

Rationale: A decrease in chest wall expansion suggests that the client may be experiencing a serious complication, such as worsening pneumonia or respiratory failure, requiring immediate medical attention. This finding indicates a potential decrease in lung function, which could lead to respiratory distress. Pleuritic pain on inspiration may be related to the disease process but does not indicate an immediate need for intervention. Dry mucus membranes in the mouth may require attention but are not as critical as a decrease in chest wall expansion. A decrease in respiratory rate could be concerning but is not as urgent as a decrease in chest wall expansion, which directly impacts respiratory function.

5. A female client makes routine visits to a neighborhood community health center. The nurse notes that this client often presents with facial bruising, particularly around the eyes. The nurse discusses prevention of domestic violence with the client even though the client does not admit to being battered. What level of prevention has the nurse applied in this situation?

• A. primary prevention
• B. secondary prevention
• C. tertiary prevention
• D. health promotion

Correct answer: B

Rationale: The correct answer is B: secondary prevention. Secondary prevention involves identifying and addressing issues early to prevent further harm. In this scenario, the nurse is intervening by discussing domestic violence prevention with the client who is showing signs of facial bruising, aiming to prevent further harm even though the client has not disclosed being battered. Choice A (primary prevention) focuses on preventing the onset of a problem before it occurs, like educating about healthy relationships before violence happens. Choice C (tertiary prevention) involves managing and treating the effects of a problem that has already occurred, such as providing counseling to a domestic violence survivor. Choice D (health promotion) aims to enhance well-being and prevent health problems through educational and environmental interventions, which may include aspects of preventing domestic violence, but in this case, the nurse's direct intervention is more about early identification and prevention of harm, aligning it with secondary prevention.

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