Nursing Elites

1. A client turns her ankle. She is diagnosed as having a Pulled Ligament. This should be documented as a:

• A. sprain.
• B. strain.
• C. subluxation.
• D. dislocation.

Correct answer: B

Rationale: The term 'strain' is the correct choice. A strain refers to the excessive stretching of a muscle or tendon, which aligns with a pulled ligament diagnosis. A sprain, on the other hand, involves ligament injury due to twisting motions. 'Subluxation' indicates a partial dislocation of a joint, not a pulled ligament. 'Dislocation' refers to the complete displacement of bones in a joint, which is not the appropriate term for a pulled ligament.

2. To improve overall health, the nurse should place the highest priority on assisting a client to make lifestyle changes for which of the following habits?

• A. drinking a six-pack of beer each day
• B. eating an occasional chocolate bar
• C. exercising twice a week
• D. using relaxation exercises to deal with stress

Correct answer: A

Rationale: To improve overall health, the nurse should prioritize assisting the client in making lifestyle changes that have the most significant impact on health. Drinking a six-pack of beer each day can have serious negative effects on health, including liver damage, increased risk of chronic diseases, and addiction. By addressing this habit first, the nurse can make a substantial positive difference in the client's health. Eating an occasional chocolate bar, exercising twice a week, and using relaxation exercises to deal with stress are beneficial habits, but they are not as detrimental to health as excessive alcohol consumption. Therefore, they are not the highest priority for immediate lifestyle changes to improve health.

3. A nurse is telling a pregnant client about the signs that must be reported to the health care provider. The nurse tells the client that the health care provider should be contacted if which occurs?

• A. Puffiness of the face
• B. Breast tenderness
• C. Morning sickness
• D. Urinary frequency

Correct answer: A

Rationale: During pregnancy, it is important to be aware of danger signs that warrant contacting the healthcare provider. Puffiness of the face, especially around the eyes, can indicate a serious condition like preeclampsia. Other danger signs include vaginal bleeding, rupture of membranes, severe abdominal pain, visual disturbances, persistent vomiting, and changes in fetal movements. Morning sickness, breast tenderness, and urinary frequency are common symptoms of pregnancy and are not typically concerning unless they become severe or persistent, and do not usually require immediate medical attention.

4. After breast reconstruction secondary to breast cancer, the nurse should recognize which of the following expected client outcomes as evidence of a favorable response to nursing interventions related to disturbed body image?

• A. maintaining adequate tissue perfusion
• B. demonstrating behaviors that reduce fears
• C. restored body integrity
• D. remaining free of infection

Correct answer: C

Rationale: The correct answer is 'restored body integrity.' This outcome is crucial in addressing disturbed body image following breast reconstruction. Restored body integrity reflects a positive perception of one's body after surgery, contributing to improved body image. Choices A, 'maintaining adequate tissue perfusion,' are more related to physiological outcomes and are not directly linked to body image concerns. Choice B, 'demonstrating behaviors that reduce fears,' is associated with anxiety management, not body image. Choice D, 'remaining free of infection,' pertains to preventing infections and does not directly address body image concerns.

5. The client has an order for 0.45 mg of Diltiazem. The medication vial has a concentration of 3 mg/mL. How many mL of the drug should be administered?

• A. 0.15 mL
• B. 6.6 mL
• C. 1.5 mL
• D. 0.65 Ml

Correct answer: A

Rationale: To calculate the amount of drug to be administered, divide the ordered dose by the concentration of the medication in the vial. In this case, 0.45 mg ÷ 3 mg/mL = 0.15 mL. Therefore, the correct answer is 0.15 mL. Choice B (6.6 mL) is incorrect as it does not result from the correct calculation. Choice C (1.5 mL) is incorrect as it is not the result of dividing the ordered dose by the concentration. Choice D (0.65 mL) is incorrect as it is not the accurate calculation based on the provided information.

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