Nursing Elites

1. Which action represents the evaluation stage of the plan of care?

• A. The nurse assigns a nursing diagnosis of Impaired Skin Integrity related to diminished skin circulation
• B. The nurse assesses the client's vital signs and asks about symptoms
• C. The nurse determines that the client is not meeting his set outcomes and makes revisions
• D. The nurse discusses the client's health history

Correct answer: C

Rationale: The correct answer is C. The evaluation stage of the nursing process involves reviewing the assessments, diagnoses, and interventions given to the client and then determining if the client is meeting expected outcomes. In this scenario, the nurse is assessing whether the client is meeting the outcomes set for their care plan and making revisions as needed. Choice A is incorrect as assigning a nursing diagnosis is part of the nursing diagnosis phase, not the evaluation phase. Choice B represents the assessment phase of the nursing process, not the evaluation phase. Choice D involves discussing the client's health history, which is more aligned with the assessment phase rather than the evaluation phase.

2. Your patient has been diagnosed with herpes simplex virus 2. Which of the following would NOT be included in your teaching of this patient?

• A. If you have symptoms, you should avoid sexual contact with other individuals.
• B. With treatment, this condition can be cured.
• C. This disease is highly contagious.
• D. You may experience tingling in the skin before an active outbreak occurs.

Correct answer: B

Rationale: The correct answer is 'With treatment, this condition can be cured.' The treatment for herpes simplex virus (HSV) is symptomatic and palliative, aimed at managing symptoms rather than curing the infection. HSV is highly contagious, so sexual contact should be avoided during active outbreaks to prevent transmission. Many patients experience a tingling sensation in the skin before an active outbreak, known as a prodrome. Educating the patient that the condition is not curable but manageable with treatment is vital to set realistic expectations and promote proper management of the disease.

3. A 3-year-old pediatric patient's mother would like to stay at the patient's bedside throughout the night as the patient seems calmer when she is present. What is the most caring and appropriate response?

• A. Reinforce visiting hours
• B. Allow her to stay for a short period beyond normal hours
• C. Allow her to stay throughout the night
• D. Offer to get bedding for a couch in the waiting room

Correct answer: C

Rationale: Allowing the mother to stay throughout the night is the most caring and appropriate response in this situation. Pediatric facilities often recognize the crucial role parents play in their child's care and are supportive of unlimited visitation. Allowing the mother to stay can help maintain the child's calmness and enhance the bond between the family and healthcare team. Reinforcing visiting hours (Choice A) may not address the specific needs of this situation where the child benefits from the mother's presence. Allowing her to stay for a short period beyond normal hours (Choice B) may not fully address the need for her continuous presence. Offering to get bedding for a couch in the waiting room (Choice D) may not be necessary if the mother can stay with her child in the patient's room.

4. What kind of preventive measures is MOST likely to be used to prevent Mary Eden from falling due to her muscular frailty?

• A. Physical therapy for muscle strengthening exercises
• B. Physical therapy for range of motion exercises
• C. Occupational therapy to help her with confusion
• D. Medications to help her sleep more

Correct answer: A

Rationale: Mary Eden, due to her muscular frailty, is at risk of falling. The most effective preventive measure in this case would be physical therapy focusing on muscle strengthening exercises. Strengthening exercises can help improve her muscle tone and stability, reducing the risk of falls. While range of motion exercises may be beneficial, they may not directly address her muscular frailty and stability concerns as effectively as muscle strengthening exercises. Occupational therapy aims to help individuals with activities of daily living and functional tasks, not confusion. Medications to induce more sleep can actually increase the risk of falls due to potential side effects like dizziness or disorientation, rather than preventing falls.

5. Mary T. was admitted to a nursing home on May 1st. On July 4th, she was diagnosed with a skin infection. This infection is considered a ________________ infection.

• A. nosocomial
• B. systemic
• C. resident flora
• D. resident aura

Correct answer: A

Rationale: The correct answer is 'nosocomial.' A nosocomial infection is defined as one that is not present upon admission to a healthcare facility but instead occurs during the patient's stay. In this case, since Mary was diagnosed with a skin infection after being admitted to the nursing home, it is considered a nosocomial infection. Nosocomial infections are a significant concern in healthcare settings, and infection control measures are in place to prevent their spread. Choices B, C, and D are incorrect. 'Systemic' refers to a condition affecting the entire body, not specific to a healthcare setting. 'Resident flora' and 'resident aura' are not commonly used terms in healthcare and do not relate to infections acquired in healthcare facilities.

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