the community health nurse is working in a multi ethnic health center in what situation should the nurse intervene
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ATI Learning System PN Medical Surgical Final Quizlet

1. The community health nurse is working in a multi-ethnic health center. In what situation should the nurse intervene?

Correct answer: D

Rationale: The correct answer is D because losing weight in an infant, especially when combined with spitting up milk, requires immediate intervention to address potential health concerns. Choice A deals with a cultural practice that may not necessarily pose an immediate health risk. Choice B, while important, does not present an immediate health threat. Choice C relates to cultural differences in communication and does not necessarily indicate a need for immediate intervention in terms of health.

2. An older adult with a diagnosis of Alzheimer's disease has been experiencing fecal incontinence, with no recent change in stool character noted by the nurse. What is the nurse's most appropriate intervention?

Correct answer: C

Rationale: The most appropriate intervention for an older adult with Alzheimer's disease experiencing fecal incontinence and no change in stool character is to toilet the client on a frequent, scheduled basis. Scheduled toileting can help manage incontinence by establishing a routine for bowel movements, which may aid in reducing episodes of fecal incontinence.

3. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which instruction should the nurse provide?

Correct answer: A

Rationale: The correct instruction for a client with COPD receiving oxygen therapy is to use oxygen continuously, even while sleeping. This is important to ensure adequate oxygenation and optimal respiratory function for clients with COPD. Continuous oxygen therapy helps maintain oxygen levels during sleep, which is crucial for individuals with COPD who may experience nighttime hypoxemia. Therefore, advising the client to use oxygen continuously, even during sleep, is essential in managing COPD and preventing complications associated with oxygen deprivation.

4. A client admitted with acute diverticulitis has experienced a sudden increase in temperature and reports a sudden onset of exquisite abdominal tenderness. The nurse's rapid assessment reveals that the client's abdomen is uncharacteristically rigid on palpation. What is the nurse's best response?

Correct answer: B

Rationale: In a client with acute diverticulitis experiencing sudden increase in temperature, exquisite abdominal tenderness, and uncharacteristic abdominal rigidity, these signs suggest a possible perforation. The nurse should promptly contact the primary care provider to report these signs, as perforation requires immediate medical attention to prevent further complications.

5. When should the charge nurse intervene based on the observed behavior?

Correct answer: B

Rationale: The hospital transporter reading a client's history and physical without a legitimate need violates patient confidentiality. This behavior requires immediate intervention to protect the client's privacy and confidentiality rights.

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