NR-442 Community Health Nursing - Set 5 - Part 3

Correct Answer: Help guests complete benefit applications and record contact information.

Completing applications and gathering contact information requires no nursing judgment and matches the community health worker's training. It also frees the nurse for assessment while keeping the benefit enrollment moving during a single encounter. Option a is incorrect because reading an induration and judging whether it is positive for a given risk group is an interpretation reserved for licensed staff. Measuring is a skill; deciding what the measurement means is not. Option c is incorrect because wound assessment and dressing selection call for clinical judgment about depth, infection, and healing. An unlicensed worker may gather supplies and offer socks, but the evaluation stays with the nurse. Option d is incorrect because initial teaching of a medication technique belongs to the nurse, who must evaluate what the guest learned. Reinforcing instruction later is different from delivering it for the first time.

Correct Answer: Carrying supplies to the treatment area

Minor-injury survivors are commonly recruited to help, and moving supplies requires no clinical judgment or assessment. Tasks that carry a predictable outcome and no risk to casualties can safely be handed to untrained helpers. Option a is incorrect because reassessment decides whether a casualty must be upgraded to immediate. Counting a rate correctly and knowing what the number means require training these survivors do not have. Option b is incorrect because tagging records a triage decision that only a trained responder may make. A wrong color sends a casualty to the wrong treatment area and can delay care until someone catches it. Option c is incorrect because bleeding control on an unstable casualty is one of only two interventions permitted during triage, and it belongs to responders. Untrained helpers also face blood exposure without protection.

Correct Answer: Record the client's own words in quotation marks

Direct quotation preserves what the client actually said, along with objective description of findings and body maps. That combination holds up later because it records observation rather than the nurse's interpretation. Option b is incorrect because translating a statement into clinical language strips out the detail that gives it weight. A paraphrase carries the writer's reading of events, and a reviewer cannot recover the original words. Option c is incorrect because dating bruises by their color has been discredited as unreliable. Writing an age into the record invites challenge and can undermine the parts of the note that were accurately observed. Option d is incorrect because naming a perpetrator records a conclusion the nurse did not witness. Investigators determine responsibility; the nurse's contribution is a factual account of findings, statements, and who was present.

Correct Answer: Move him to a warm place and begin rewarming.

Shivering, slowed speech, and cold stiff hands after hours in a storm point to hypothermia, which is immediately life-threatening. Warmth and shelter come before every other concern, and the rest of the visit follows once he is stable. Option a is incorrect because a housing conversation asks a man who is cognitively slowed by cold to weigh options he cannot process. Housing remains the long-term goal, but a person freezing in a doorway cannot engage with it. Option b is incorrect because infectious disease screening belongs in an outreach encounter once the person is safe. Testing a hypothermic man in the street delays warming and produces results that no one can act on immediately. Option d is incorrect because dry socks help the feet while the core temperature keeps falling. Foot care is genuine outreach work and should happen later in the same encounter, after the threat to life has been handled.

Correct Answer: Financial exploitation by a relative

Unpaid bills and lost utilities despite adequate income, appearing just after someone new took over the accounts, are the classic markers of improper use of an older adult's funds by a person in a trusted position. Option a is incorrect because neglect describes a caregiver failing to supply food, hygiene, medication, or shelter. The problem here is money leaving the account, not care being withheld at the bedside. Option b is incorrect because psychological abuse produces mental anguish through intimidation, humiliation, or isolation. No verbal or emotional conduct is described, and the findings all trace back to the man's finances. Option c is incorrect because self-neglect means the older adult himself fails to meet his own needs. Another person assumed control of the account, which shifts responsibility for the unpaid bills away from him.

Correct Answer: Reasonable suspicion obligates the nurse to report

Mandated reporting is triggered by reasonable suspicion, not certainty, and it does not depend on the client's permission. The nurse reports to Adult Protective Services and the agency, not the nurse, investigates. Option a is incorrect because proof is what an agency establishes after investigating. Holding a report until the evidence is conclusive leaves the client in the same household while the harm continues. Option c is incorrect because consent governs ordinary disclosure of health information, and a mandated report is a recognized exception to that rule. A vulnerable adult's wish to stay silent does not cancel the legal duty. Option d is incorrect because gathering evidence is outside the reporter's role and can compromise a later inquiry. Nurses describe what they observed; trained investigators decide what happened and what should be done.

Correct Answer: The second client's findings warrant private assessment

Bruises over the forearms and shins in a man on an anticoagulant who bumps furniture fit fragile skin and known trauma. Unexplained bruising on protected areas such as the trunk and inner thighs does not. Option a is incorrect because thinning skin explains injury only where the body actually strikes something. Areas shielded by clothing and furniture rarely take accidental impact, so that pattern still needs an explanation. Option b is incorrect because reporting everything indiscriminately would flood the agency and would label a man whose injuries have a plausible medical cause. Suspicion has to rest on findings that the history does not account for. Option c is incorrect because his anticoagulant therapy, fragile skin, and described contact with furniture together account for the location and appearance of the injuries. Nothing in his picture conflicts with the stated mechanism.

Correct Answer: The woman who reports a recent strangulation event

Strangulation is a strong predictor of later homicide and can cause airway swelling or vascular injury hours to days afterward, sometimes with no external marks, so this woman needs urgent medical evaluation. Option b is incorrect because job loss is a genuine stressor that raises household risk over time. It does not carry the immediate physiologic danger that makes one of these four an urgent clinical problem today. Option c is incorrect because attending a support group is a protective development worth reinforcing at the next contact. Nothing in that description signals a rise in lethality requiring the nurse's attention ahead of the others. Option d is incorrect because an apology places the relationship in the honeymoon phase, when acute risk is temporarily lower. The pattern will repeat, yet it does not outrank a finding that can kill within days.

Correct Answer: Obtain weight and blood pressure before the prescriber visit.

Measuring weight and blood pressure is a standard monitoring task within the practical nurse's scope, and it supplies the metabolic data the prescriber needs. The registered nurse keeps the assessment, planning, and evaluation. Option a is incorrect because a first risk assessment demands clinical judgment about plan, means, and intent, together with an immediate decision about safety. That evaluation stays with the registered nurse or a qualified clinician. Option c is incorrect because creating a plan of care is a registered nurse function tied to the nursing process. A practical nurse contributes observations and carries out interventions but does not originate the plan. Option d is incorrect because triage decisions rest on interpreting findings and weighing urgency. Sending a client home or into an urgent evaluation is exactly the judgment that cannot be handed to an assisting staff member.

Correct Answer: Recovery, because the response is being evaluated

Evaluating how the response teams performed and producing an after-action report belong to recovery. That review closes the loop, feeding lessons learned back into a revised plan and into the next preparedness cycle. Option a is incorrect because preparedness covers writing and exercising a plan before an event. Evaluating a drill would sit there, but this nurse is judging an actual response that has already occurred. Option b is incorrect because response covers the hours to weeks of saving lives during and just after impact. The fire is out, casualties are managed, and the community has moved past that window. Option d is incorrect because mitigation targets the hazard through engineering, codes, or zoning decisions. Rebuilding to a stricter standard would qualify, whereas reviewing team performance examines the response instead of the threat.