Nursing Elites

1. A client has AIDS. Which of these findings indicate possible infection?

• A. Respirations; 22 breaths per minute
• B. Client ambulates 20 feet
• C. Purulent drainage
• D. Oxygen saturation; 97% on room air

Correct answer: C

Rationale:

2. What is the term for a ringing in the ears reported by the client?

• A. Weber
• B. Rinne
• C. Pinna
• D. Tinnitus

Correct answer: D

Rationale: Tinnitus is the correct answer. Tinnitus refers to the perception of noise or ringing in the ears. This condition can be constant or intermittent and may be caused by various factors such as exposure to loud noises, ear infections, or underlying health conditions. Choices A, B, and C are incorrect as Weber and Rinne tests are related to hearing assessment, while the pinna is the external part of the ear responsible for collecting sound waves.

3. Which of the following would be the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery?

• A. Client will increase mobility by the time of discharge from hospital
• B. Client will demonstrate effective breathing pattern when ambulating throughout hospital stay
• C. Client will increase activity tolerance by discharge from the hospital
• D. Client will remain free from falls throughout their hospital stay

Correct answer: D

Rationale:

4. What is not a potential complication of RA?

• A. Paresthesia's
• B. Fibromyalgia
• C. Joint deformity
• D. Dry eyes

Correct answer: A

Rationale:

5. What is the priority nursing diagnosis for a client with immobility?

• A. Constipation related to immobility
• B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
• C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
• D. Risk for disuse syndrome as evidenced by immobility

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.

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