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The public health nurse is assigned to the population of clients in an inner-city community. The nurse identifies which of the following as a priority intervention?

A.

Develop a survey on teen pregnancies

B.

Hold a focus group to discuss immunizations

C.

Perform a windshield survey

D.

Interview the elderly at the senior’s center

Answer and Explanation

The Correct Answer is C

Choice A reason:

Developing a survey on teen pregnancies is important for understanding the prevalence and factors contributing to teen pregnancies in the community. However, it is not the most immediate priority intervention. Surveys are useful for data collection but do not provide immediate insights into the overall community health needs.

 

Choice B reason:

Holding a focus group to discuss immunizations is valuable for gathering community input and addressing concerns about vaccinations. While this is an important public health activity, it is more specific and does not provide a comprehensive overview of the community’s health needs.

 

Choice C reason:

Performing a windshield survey is a priority intervention for a public health nurse assigned to a new community. This type of survey involves systematically observing the community to gather information about its overall health status, resources, and needs. It provides a broad overview that can inform more targeted interventions and programs.

 

Choice D reason:

Interviewing the elderly at the senior’s center is important for understanding the specific needs of this population group. However, it is a more focused intervention and does not provide a comprehensive assessment of the entire community’s health needs.


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Correct Answer is D

Explanation

Choice A reason:

Limiting fluid intake to prevent incontinence is not recommended as it can lead to dehydration and other complications. Proper hydration is essential for overall health, and other strategies should be used to manage incontinence.

Choice B reason:

Administration of antispasmodic medication can help manage bladder spasms and incontinence, but it is not the highest priority intervention. While medication can be part of the treatment plan, preventing skin breakdown is more critical in the immediate care of a client with reflex incontinence.

Choice C reason:

Kegel exercises to strengthen the pelvic floor can be beneficial for managing incontinence, but they may not be effective for clients with paralysis following a spinal cord injury. These exercises require voluntary muscle control, which may be impaired in such clients.

Choice D reason:

Regular perineal care to prevent skin breakdown is the highest priority intervention for a client with reflex incontinence. Incontinence can lead to skin irritation, breakdown, and infection if not managed properly. Ensuring good perineal hygiene helps prevent these complications and promotes overall skin health.

Correct Answer is A

Explanation

Choice A reason:

Hypertension is a common manifestation of increased intracranial pressure (ICP). As ICP rises, the body attempts to maintain cerebral perfusion by increasing blood pressure. This compensatory mechanism helps ensure that the brain continues to receive adequate blood flow despite the elevated pressure.

Choice B reason:

Tinnitus, or ringing in the ears, is not a typical manifestation of increased ICP. While it can be a symptom of various conditions, it is not specifically associated with elevated intracranial pressure.

Choice C reason:

Hypotension, or low blood pressure, is not a manifestation of increased ICP. In fact, the body typically responds to increased ICP with hypertension to maintain cerebral perfusion. Hypotension would be concerning for other reasons but is not indicative of elevated intracranial pressure.

Choice D reason:

Tachycardia, or an increased heart rate, is not a primary manifestation of increased ICP. While changes in heart rate can occur with severe neurological conditions, hypertension is a more direct indicator of elevated intracranial pressure.

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