on a repeat home visit to see an 84 year old widow the nurse discovers that the client is unkempt smells of stale urine and does not recognize her nei
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Nursing Elites

HESI RN

HESI Community Health

1. During a repeat home visit to see an 84-year-old widow, the nurse discovers that the client is unkempt, smells of stale urine, and does not recognize her neighbors or the nurse. What action should the nurse take?

Correct answer: C

Rationale: In this scenario, the nurse should prioritize completing a physical and mental exam on the client. This action is crucial to assess the client's health status comprehensively and identify any underlying issues contributing to her unkempt appearance, odor of stale urine, and confusion. Calling the pharmacy to determine medications (Choice A) may be important but is not the immediate priority. Seeking family assistance (Choice B) can be helpful, but the client's condition requires a thorough assessment first. While adult protective services (Choice D) may be necessary in the future, the immediate action should be to assess the client's physical and mental health status.

2. Because this year's demographics reflect that a large percentage of the population is less than 19 years of age, a community group proposes building a new well-child clinic. Which question indicates that the nurse understands the potential gaps in this data?

Correct answer: A

Rationale: Option A is the correct answer because understanding the percentage of the population under 19 years of age in each of the previous five years helps to determine if the high percentage of youth is a consistent trend or a recent change. This information is crucial for assessing the need for a new well-child clinic. Choices B, C, and D are incorrect because they do not directly address the gaps in the data related to the age distribution trend over time, which is essential for making an informed decision about the necessity of the proposed clinic.

3. A school nurse is organizing a vaccination clinic for middle school students. Which vaccine is most important for the nurse to include?

Correct answer: B

Rationale: The most important vaccine for the school nurse to include in the vaccination clinic for middle school students is the tetanus, diphtheria, and pertussis (Tdap) vaccine. Tdap is recommended for preteens as part of the routine vaccination schedule to protect against these serious diseases. Hepatitis B, varicella, and MMR vaccines are also important but for this specific age group, Tdap takes precedence to ensure protection against tetanus, diphtheria, and pertussis.

4. The school nurse is preparing a presentation on the importance of physical activity for elementary school students. Which benefit should the nurse emphasize?

Correct answer: A

Rationale: The correct answer is A: Improved academic performance. Physical activity has been shown to improve academic performance by enhancing concentration and cognitive function. This benefit is particularly important for elementary school students who are developing foundational skills. Choice B, increased social interactions, while important for overall development, may not directly relate to the academic aspect that the nurse is focusing on. Choice C, enhanced physical strength, is a valid benefit of physical activity but may not be as relevant to academic performance as the ability to concentrate and learn. Choice D, better sleep patterns, is also a valuable outcome of physical activity but is not as directly linked to academic performance as improved cognitive function.

5. The client, who is 6 weeks pregnant, is being educated by the nurse on prenatal care. Which statement indicates that the client comprehends the nurse's instructions?

Correct answer: D

Rationale: The correct answer is D. During pregnancy, it is crucial to avoid taking any medication without consulting a healthcare provider to prevent harm to the developing fetus. Choices A, B, and C are important aspects of prenatal care but do not specifically address the potential risks associated with taking medications during pregnancy. Increasing intake of vitamin C (Choice A) is beneficial but does not address medication safety. Avoiding alcohol and tobacco (Choice B) is essential, but the question focuses on medication safety. Taking folic acid supplements (Choice C) is vital for neural tube development but does not cover the broader topic of medication safety.

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