Nursing Elites

1. Which of the following is an example of the intervention phase of the individualized nursing care plan for a client who receives a colostomy after a bowel resection?

• A. Taking a health history and performing a physical exam prior to the procedure
• B. Instructing the client about how to care for his colostomy stoma
• C. Developing goals that state the client will ambulate three times a day
• D. Determining that the client may need more support at home after dismissal

Correct answer: B

Rationale: The intervention stage of the individualized nursing care plan is where the nurse provides care, treatments, or education to help the client meet the devised outcomes. Instructing the client about how to care for his colostomy stoma is the correct example of an intervention as it directly involves providing education and guidance to the client on post-operative care. This intervention supports the process of helping the client meet the outcomes designed for this case, which is to enable the client to properly care for his colostomy after a bowel resection. The other options do not directly involve interventions aimed at assisting the client in meeting the specific care needs related to the colostomy procedure.

2. A patient who has been diagnosed with vasospastic disorder (Raynaud's disease) complains of cold and stiffness in the fingers. Which of the following descriptions is most likely to fit the patient?

• A. An adolescent male
• B. An elderly woman
• C. A young woman
• D. An elderly man

Correct answer: C

Rationale: The correct answer is 'A young woman.' Raynaud's disease is most common in young women and is often associated with rheumatologic disorders like lupus and rheumatoid arthritis. This disorder involves vasospasm of the arteries, leading to reduced blood flow to the fingers and toes. Typically, Raynaud's affects the fingers, and in some cases, it can affect the toes. Only rarely does it involve other body parts such as the nose, ears, nipples, and lips. Choices B, C, and D are less likely as Raynaud's disease predominantly affects young women, although it can occur in other demographic groups as well.

3. Mr. Freeman has difficulty getting out of bed. The nurse should encourage Mr. Freeman to ______________.

• A. ask for assistance before getting out of bed.
• B. remain in bed because it is safer and he will not fall.
• C. instruct him to stand up quickly from the bed.
• D. lean forward and push up and off the bed.

Correct answer: A

Rationale: The nurse should encourage Mr. Freeman to use his call bell and ask for assistance before getting out of bed. This can prevent him from falling. Patients should not stay in bed; they should be encouraged to get out of bed as much as possible to prevent complications like pressure ulcers and muscle weakness. Instructing a patient to stand up quickly from the bed is unsafe as it can lead to dizziness and falls. Similarly, leaning forward and pushing off the bed can increase the risk of falls and should be avoided. Asking for assistance is the safest and most appropriate option to ensure patient safety and prevent accidents.

4. Which of the following situations warrants a measurement for orthostatic hypotension?

• A. A 36-year-old male with a spinal injury
• B. An 86-year-old female with significantly altered mental status
• C. A 58-year-old female with near-syncope
• D. A 41-year-old male with acute deep vein thrombosis

Correct answer: C

Rationale: The correct answer is a 58-year-old female with near-syncope. Orthostatic hypotension is a drop in blood pressure of greater than 20 mmHg systolic when moving from a sitting or lying position to standing. Patients at higher risk include those with syncope or near-syncope, symptomatic hypovolemia, and those prone to falls. The other choices are less likely to present with orthostatic hypotension. A spinal injury, altered mental status, and acute deep vein thrombosis are not directly associated with the immediate need for orthostatic hypotension measurement.

5. Which of the following is a true statement about assessing blood pressure by palpation?

• A. Only the diastolic blood pressure can be assessed through palpation.
• B. The palpation technique is most useful for infants and small children.
• C. Hypertension is a common condition that might need to be assessed through blood pressure palpation.
• D. Only the systolic blood pressure can be assessed through palpation.

Correct answer: D

Rationale: When assessing blood pressure by palpation, it is important to note that only the systolic blood pressure can be determined accurately using this method. Diastolic blood pressure cannot be reliably assessed through palpation. The palpation technique is particularly useful in situations where traditional blood pressure measurement methods are challenging, such as in infants, small children, or individuals with low blood pressure that is difficult to hear. Hypertension, a common condition characterized by elevated blood pressure, is typically assessed using auscultation rather than palpation. Therefore, the correct statement is that only the systolic blood pressure can be assessed through palpation.

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