Nursing Elites

1. A client was admitted with a diagnosis of pneumonia. When auscultating the client's breath sounds, the nurse hears inspiratory crackles in the right base. Temperature is 102.3 degrees Fahrenheit orally. What finding would the nurse expect?

• A. Flushed skin
• B. Bradycardia
• C. Mental confusion
• D. Hypotension

Correct answer: C

Rationale: The correct answer is C: Mental confusion. In this scenario, the client's high fever and pneumonia diagnosis indicate an infection. Infections, especially in older adults, can lead to mental confusion due to the body's systemic response to the infection. Flushed skin (choice A) is more commonly associated with fever but does not specifically relate to the client's condition. Bradycardia (choice B) and hypotension (choice D) are less likely findings in a client with pneumonia and a high fever; instead, tachycardia and increased blood pressure are more commonly seen in response to infection.

2. The nurse is planning care for a client with increased intracranial pressure. The best position for this client is

• A. Trendelenburg
• B. Prone
• C. Semi-Fowler's
• D. Side-lying with head flat

Correct answer: C

Rationale: The correct answer is C, Semi-Fowler's. This position helps to reduce intracranial pressure by promoting venous drainage from the head while maintaining adequate oxygenation. Option A, Trendelenburg position, is incorrect as it involves placing the patient with the head lower than the body, which can increase intracranial pressure. Option B, Prone position, is also incorrect as it involves lying on the stomach, which can further elevate intracranial pressure. Option D, Side-lying with head flat, does not provide the same benefits as the Semi-Fowler's position in terms of promoting venous drainage and maintaining oxygenation in a client with increased intracranial pressure.

3. An activity designed to diagnose and treat a disease or condition in its earliest stages, before it becomes full-blown, would be classified as:

• A. primary prevention
• B. secondary prevention
• C. tertiary prevention
• D. health education

Correct answer: B

Rationale: The correct answer is B, secondary prevention. Secondary prevention focuses on early diagnosis and intervention to prevent the progression of a disease or condition. This involves detecting and treating the illness in its early stages to reduce its impact. Choice A, primary prevention, aims to prevent the development of a disease or injury before it occurs by promoting healthy behaviors. Choice C, tertiary prevention, involves managing and improving the quality of life of individuals with established conditions to prevent complications and further deterioration. Choice D, health education, refers to providing information and promoting awareness about health issues to enable individuals to make informed decisions and adopt healthy behaviors.

4. Which of the following statements about TB treatment is INCORRECT?

• A. Combination of 3-4 anti-TB drugs is the treatment of choice
• B. Single drug therapy is appropriate
• C. Treatment renders patients non-infectious and cured
• D. Tuberculosis is a curable disease

Correct answer: B

Rationale: The correct answer is B. Single drug therapy is not appropriate for TB due to the risk of developing resistance. The most effective approach to TB treatment is a combination of 3-4 anti-TB drugs. This combination helps to prevent the development of drug resistance and improve treatment outcomes. Choice C is correct as TB treatment, when completed successfully, renders patients non-infectious and cured. Choice D is also correct as tuberculosis is indeed a curable disease with appropriate treatment. Therefore, the incorrect statement is B.

5. A 16-year-old female client returns to the clinic because she is pregnant for the third time by a new boyfriend. Which vaccine should the nurse plan to administer?

• A. Measles-mumps-rubella.
• B. Hepatitis B.
• C. Human papillomavirus.
• D. Pneumococcal.

Correct answer: B

Rationale: The correct answer is B: Hepatitis B. The Hepatitis B vaccine is crucial for pregnant women as it helps prevent transmission of the virus to the baby during childbirth. Measles-mumps-rubella vaccine (choice A) is not directly related to the current situation of the client being pregnant. Human papillomavirus vaccine (choice C) is recommended for adolescents but is not specifically indicated in this case. Pneumococcal vaccine (choice D) is not a priority in this scenario compared to Hepatitis B, which is crucial for preventing vertical transmission.

Similar Questions