Nursing Elites

1. When assessing the integumentary system of a client with anorexia nervosa, which finding would support the diagnosis?

• A. Preoccupation with calories
• B. Thick body hair
• C. Sore tongue
• D. Dry, brittle hair

Correct answer: D

Rationale: Dry, brittle hair is a common sign of malnutrition, often seen in clients with anorexia nervosa. In anorexia nervosa, the body lacks essential nutrients due to severe calorie restriction, leading to dryness and brittleness of the hair. Choices A, B, and C are less likely to directly indicate anorexia nervosa. Preoccupation with calories can be a behavioral symptom, thick body hair is not a typical finding associated with anorexia nervosa, and a sore tongue is more commonly related to nutritional deficiencies like vitamin deficiencies rather than anorexia nervosa.

2. Determining nursing care priorities is a part of which of the following steps for determining and fulfilling the nursing care needs of the patient?

• A. Evaluation
• B. Planning
• C. Implementation
• D. Assessment

Correct answer: B

Rationale: Corrected Rationale: Planning in nursing involves setting priorities based on the identified patient needs, establishing goals, and developing a plan of care. Evaluation involves assessing the effectiveness of the care provided, implementation is the phase where the care plan is carried out, and assessment is the initial step of collecting data to identify the patient's needs. Therefore, in the context of determining nursing care priorities, the correct step is Planning (choice B).

3. The client diagnosed with diabetes mellitus type 2 is admitted to the hospital with cellulitis of the right foot secondary to an insect bite. Which intervention should the nurse implement first?

• A. Administer intravenous antibiotics
• B. Apply warm moist packs every two hours
• C. Elevate the right foot on two pillows
• D. Teach the client about skin and foot care

Correct answer: A

Rationale: Administering intravenous antibiotics is the priority intervention in this situation. Cellulitis is a bacterial infection that can spread rapidly, especially in individuals with diabetes. Immediate antibiotic therapy is crucial to prevent the infection from worsening and causing serious complications. Applying warm moist packs, elevating the foot, and teaching the client about skin and foot care are important interventions but should come after initiating antibiotic treatment to address the underlying infection.

4. The nurse instructs a client 5 days after a lumbar laminectomy with spinal fusion about how to move from a supine position to standing at the left side of the bed with a walker. Which of the following directions by the nurse is BEST?

• A. Raise the head of the bed so you are sitting straight up, bend your knees, and swing your legs to the side and then to the floor
• B. Rock your body from side to side, going further each time until you build up enough momentum to be lying on your right side, and then raise your trunk toward your toes
• C. Reach over to the left side rail with your right hand, pull your body onto its side, bend your upper leg so the foot is on the bed, and push down to elevate your trunk
• D. Focus on using your arms, the left elbow as a pivot with the left hand grasping the mattress edge and the right hand pushing on the mattress above the elbow, then slide your legs over the side of the mattress

Correct answer: C

Rationale: The correct method described in option C helps maintain spinal alignment while moving from a lying to a standing position, which is crucial after a lumbar laminectomy with spinal fusion. This technique minimizes strain on the back and promotes safe movement. Choices A, B, and D involve movements that could potentially strain the back, increase the risk of injury, or compromise the spinal alignment, making them less optimal for the client recovering from such surgery.

5. What condition should a patient on long-term steroid therapy be monitored for?

• A. Hyperglycemia
• B. Hypothyroidism
• C. Hypertension
• D. Osteoporosis

Correct answer: D

Rationale: Correct! Patients on long-term steroid therapy should be monitored for osteoporosis. Prolonged use of steroids can lead to decreased bone density, increasing the risk of osteoporosis. Hyperglycemia is more commonly associated with steroid-induced diabetes rather than long-term steroid use. Hypothyroidism is not a typical complication of long-term steroid therapy. While steroids can contribute to hypertension, osteoporosis is a more prominent concern in this scenario.

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