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. At a routine health assessment, a client tells the nurse that she is planning a pregnancy in the near future. She asks about preconception diet changes. Which of the statements made by the nurse is best?

• A. Include fibers in your daily diet.
• B. Increase green leafy vegetable intake.
• C. Drink a glass of milk with each meal.
• D. Eat at least 1 serving of fish weekly.

Correct answer: B

Rationale: The correct answer is B: "Increase green leafy vegetable intake." This is the best advice because green leafy vegetables are rich in folic acid, which is essential for fetal development and helps prevent neural tube defects. Choice A is not specific enough and does not address the importance of folic acid. Choice C, drinking milk with each meal, does not provide the necessary folic acid intake. Choice D, eating fish weekly, is not as crucial for preconception diet changes as increasing folic acid intake.

3. When a nurse teaches a community about the importance of regular health screenings, this activity falls under which level of prevention?

• A. Primary prevention
• B. Secondary prevention
• C. Tertiary prevention
• D. Quaternary prevention

Correct answer: B

Rationale: The correct answer is B: Secondary prevention. Secondary prevention aims to detect and treat disease early to prevent complications. Teaching about the importance of regular health screenings helps in early detection and intervention, which aligns with the goals of secondary prevention. Choice A, Primary prevention, involves actions to prevent the onset of a health condition. Choice C, Tertiary prevention, focuses on managing and treating existing conditions to prevent further complications. Choice D, Quaternary prevention, relates to actions taken to mitigate or avoid unnecessary interventions, over-medicalization, and the consequences of unnecessary treatment.

4. While discussing the science of nursing, the nurse identifies the domain of nursing theory. Which linkages should the nurse provide to describe nursing's paradigm?

• A. The person, the environment or situation, and health.
• B. Stress reduction, self-care, and a systems model.
• C. Curative care, restorative care, and terminal care.
• D. Self-actualization, fundamental needs, and belonging.

Correct answer: A

Rationale: The correct answer is A: 'The person, the environment or situation, and health.' In nursing theory, the paradigm includes these core components: the person receiving care, the environment or situation influencing care, and the goal of achieving optimal health outcomes. Choices B, C, and D are incorrect as they do not align with the fundamental aspects of nursing theory and its paradigm.

5. A Hispanic client confides in the nurse that she is concerned that staff may give her newborn the 'evil eye.' The nurse should communicate to other personnel that the appropriate approach is to

• A. Touch the baby after looking at him
• B. Talk very slowly while speaking to him
• C. Avoid touching the child
• D. Look only at the parents

Correct answer: A

Rationale: In some Hispanic cultures, touching the baby after looking at them is believed to prevent the 'evil eye.' Respecting this cultural belief can help build trust and comfort with the client. Choices B, C, and D are incorrect as they do not address the specific cultural concern raised by the client. Talking slowly or avoiding touching the child does not relate to the belief in the 'evil eye.' Similarly, focusing only on the parents does not address the client's worry about the newborn receiving the 'evil eye.'

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