Nursing Elites

1. A 67-year-old client is admitted with substernal chest pain with radiation to the jaw. His admitting diagnosis is Acute Myocardial Infarction (MI). The priority nursing diagnosis for this client during the immediate 24 hours is

• A. Constipation related to immobility
• B. High risk for infection
• C. Impaired gas exchange
• D. Fluid volume deficit

Correct answer: C

Rationale: The correct answer is C: Impaired gas exchange. In a client with an acute myocardial infarction, impaired gas exchange is a priority nursing diagnosis due to compromised heart function, which affects oxygenated blood circulation. Close monitoring and interventions are crucial to ensure adequate oxygenation. Choices A, B, and D are incorrect: A) Constipation related to immobility is not the priority in this acute situation; B) High risk for infection is not the immediate concern related to the client's primary diagnosis; D) Fluid volume deficit, while important, is not the priority compared to addressing impaired gas exchange in acute MI.

2. A home health nurse knows that a 70-year-old male client who is convalescing at home following a hip replacement is at risk for developing decubitus ulcers. Which physical characteristic of aging contributes to such a risk?

• A. 16% increase in overall body fat.
• B. Reduced melanin production.
• C. Thinning of the skin with loss of elasticity.
• D. Calcium loss in the bones.

Correct answer: C

Rationale: Thinning of the skin with loss of elasticity is the physical characteristic of aging that contributes to an increased risk of developing decubitus ulcers. As individuals age, the skin becomes thinner and loses its elasticity, making it more susceptible to damage from pressure, leading to the formation of pressure ulcers. Choices A, B, and D are incorrect as they do not directly contribute to the development of decubitus ulcers in this context.

3. A community health nurse is planning to implement an outreach program for a community group. Which criteria should the nurse clarify about the program when examining sources for funding?

• A. Focuses on addressing multiple health problems or concerns.
• B. Identifies populations and individuals in need of healthcare services.
• C. Evaluates differences in health services and health status among populations.
• D. Provides healthcare services to community members in local factories, schools, and churches.

Correct answer: B

Rationale: Identifying populations and individuals in need of healthcare services is essential when seeking funding for an outreach program. This criterion helps demonstrate the relevance and impact of the program on specific groups requiring healthcare services. Choice A is incorrect because while addressing multiple health problems is important, identifying the target population in need of services is more critical for funding considerations. Choice C is incorrect as evaluating variations in health services and status, though valuable, is not directly related to securing funding. Choice D is incorrect as offering services in various community locations is a component of the program's implementation, not a criterion for funding.

4. Under the present system, which of the following is the local government unit responsible for?

• A. Operation and maintenance of health facilities
• B. All of these activities
• C. Implementation of health programs/projects
• D. Delivery of health services

Correct answer: B

Rationale: Under the present system, the local government unit is responsible for all the listed activities. This includes the operation and maintenance of health facilities, implementation of health programs/projects, and delivery of health services. Therefore, choice B, 'All of these activities,' is the correct answer. Choices A, C, and D are incorrect because they are all responsibilities that fall under the local government unit's jurisdiction as well.

5. A client has been admitted for meningitis. In reviewing the laboratory analysis of cerebrospinal fluid (CSF), the nurse would expect to note

• A. High protein
• B. Clear color
• C. Elevated sed rate
• D. Increased glucose

Correct answer: A

Rationale: High protein levels in the cerebrospinal fluid are indicative of bacterial meningitis, as the presence of bacteria in the CSF leads to increased protein production. Elevated protein levels can be seen in inflammatory conditions like meningitis. Choice B, clear color, is not expected in meningitis as it is typically associated with cloudy or turbid CSF. Elevated sed rate (choice C) and increased glucose (choice D) are not typically associated with the laboratory findings seen in meningitis.

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