A school nurse is implementing health screening. Which of the following assessment findings should the nurse recognize as the highest priority?
A child who has a BMI of 18
An adolescent who has scoliosis
An adolescent who has psoriasis
A child who has nits
The Correct Answer is D
Choice A reason: A child who has a BMI of 18 is not the highest priority, as it is within the normal range for children. BMI, or body mass index, is a measure of weight relative to height. A BMI of 18 is considered healthy for children aged 2 to 20 years, according to the Centers for Disease Control and Prevention (CDC). The nurse should monitor the child's growth and development and provide nutrition education as needed.
Choice B reason: An adolescent who has scoliosis is not the highest priority, as it is a common and usually mild condition. Scoliosis is a sideways curvature of the spine that affects about 3% of adolescents. Most cases of scoliosis are mild and do not require treatment, although some may need braces or surgery. The nurse should refer the adolescent to a specialist for further evaluation and management.
Choice C reason: An adolescent who has psoriasis is not the highest priority, as it is a chronic and non-contagious condition. Psoriasis is a skin disorder that causes red, scaly patches on the skin that may itch or burn. Psoriasis is not curable, but it can be controlled with medications, creams, or light therapy. The nurse should provide education and support to the adolescent and encourage them to seek medical care as needed.
Choice D reason: A child who has nits is the highest priority, as it indicates a parasitic infestation that can spread to others. Nits are the eggs of head lice, which are tiny insects that live on the scalp and feed on blood. Head lice can cause itching, irritation, and infection of the scalp. The nurse should isolate the child and notify the parents and the school staff. The nurse should also provide instructions on how to treat the infestation and prevent reinfestation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Determining potential funding sources for the program is an important action, but not the first one. The nurse should first assess the needs of the target population, such as the number of older adults who need the service, their nutritional status, their preferences, and their barriers to access food.
Choice B reason: Inquiring about the availability of volunteers is an important action, but not the first one. The nurse should first assess the needs of the target population, and then plan the resources and personnel needed to implement the program.
Choice C reason: Identifying alternative solutions to address concerns is an important action, but not the first one. The nurse should first assess the needs of the target population, and then identify the possible challenges and solutions to deliver the service effectively and efficiently.
Choice D reason: Performing a needs assessment is the first action that the nurse should take, as it provides the basis for planning, implementing, and evaluating the program. A needs assessment involves collecting and analyzing data about the health status, needs, and resources of the target population and the community. It helps to identify the gaps, priorities, and goals of the program.
Correct Answer is ["B","C","E"]
Explanation
Choice A reason: Using seasonings to enhance the flavor of foods is not an intervention that the nurse should initiate. This may worsen the nausea and vomiting, as some seasonings may be too spicy, salty, or acidic for the client. The nurse should advise the client to avoid foods that are greasy, fried, or have strong odors, and to choose bland, soft, or liquid foods that are easy to digest.
Choice B reason: Providing sips of room temperature ginger ale between meals is an intervention that the nurse should initiate. This can help to settle the stomach and reduce the nausea and vomiting. Ginger has antiemetic properties that can inhibit the serotonin receptors in the gastrointestinal tract. The nurse should also encourage the client to drink plenty of fluids to prevent dehydration.
Choice C reason: Maintaining the head of the client's bed in an elevated position after eating is an intervention that the nurse should initiate. This can help to prevent the reflux of gastric contents and reduce the nausea and vomiting. The nurse should also instruct the client to eat small, frequent meals, and to avoid lying down for at least an hour after eating.
Choice D reason: Offering 120 ml (4 oz.) of cold 2% milk as a meal replacement is not an intervention that the nurse should initiate. This may worsen the nausea and vomiting, as milk and dairy products may be difficult to digest and may increase the production of mucus. The nurse should suggest other sources of protein and calcium, such as soy milk, yogurt, or cheese.
Choice E reason: Assisting the client in using guided imagery is an intervention that the nurse should initiate. This can help to reduce the nausea and vomiting, as well as the anxiety and stress associated with chemotherapy. Guided imagery is a relaxation technique that involves creating positive mental images that can distract the client from the unpleasant sensations and feelings. The nurse should help the client to choose an image that is soothing and comforting, and to focus on the sensory details of the image.
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