A community health nurse is addressing the issue of elder abuse in the community. Which intervention should be prioritized?

Correct Answer: D

Rationale: The prioritized intervention for addressing elder abuse in the community should be the creation of a confidential hotline for reporting abuse. A confidential hotline offers a safe and accessible way for individuals to report elder abuse and seek help promptly. Providing education on the signs of elder abuse (Choice A) is important but may not directly address immediate reporting and intervention needs. Setting up a support group for elder abuse survivors (Choice B) is beneficial for emotional support but may not address the primary need for reporting abuse. Partnering with local law enforcement to increase patrols (Choice C) focuses on prevention rather than providing a direct reporting mechanism for victims.

Correct Answer: A

Rationale: In this scenario, option A, "I will use my albuterol inhaler before exercising," indicates a need for further teaching. This statement is incorrect because using the albuterol inhaler before exercising is actually a recommended practice for individuals with COPD to help open up the airways and improve breathing during physical activity. Options B, C, and D are all correct statements for a client with COPD. Option B, "I will avoid secondhand smoke," is important because exposure to smoke can exacerbate COPD symptoms. Option C, "I will get a flu shot every year," is crucial as individuals with COPD are at higher risk of developing complications from the flu. Option D, "I will limit my fluid intake to 2 liters per day," is also a valid statement as excessive fluid intake can worsen symptoms in COPD patients with heart failure. Educationally, understanding the correct management strategies for COPD is vital for nurses working in community health settings. This question highlights the importance of thorough patient education to ensure optimal self-management and quality of life for individuals with chronic conditions like COPD.

Correct Answer: D

Rationale: An elevated ammonia level of 80 mcg/dL indicates hepatic encephalopathy, a serious complication of liver cirrhosis that requires immediate intervention. Ammonia is a neurotoxin that accumulates in the blood due to impaired liver function, leading to cognitive impairment and altered mental status. Monitoring and lowering ammonia levels are crucial in managing hepatic encephalopathy to prevent further neurological deterioration. Prothrombin time, bilirubin, and albumin levels are important parameters in assessing liver function and overall health status in clients with liver cirrhosis, but an elevated ammonia level poses an immediate threat to neurological function and warrants prompt attention.

Correct Answer: B

Rationale: The correct answer is the 45-year-old father who is overweight and has high cholesterol. He possesses multiple risk factors for diabetes, indicating a need for prioritized evaluation and intervention. The mother's hypertension, the daughter's inactivity, and the son's normal weight and activity level are important factors to consider but do not present as immediate red flags for diabetes risk compared to the father's combination of being overweight and having high cholesterol.

Correct Answer: B

Rationale: Shortness of breath is a critical sign that can indicate heart failure or pulmonary edema, conditions that require immediate intervention in a client with a suspected myocardial infarction. Chest pain radiating to the left arm is a classic symptom of a myocardial infarction but may not necessitate immediate intervention compared to severe shortness of breath. Nausea and vomiting can be present in myocardial infarction but are not as urgent as shortness of breath. Diaphoresis, or sweating, is a common symptom of a myocardial infarction but may not be as immediately concerning as significant shortness of breath.