Nursing Elites

1. A client was re-admitted to the hospital following a recent skull fracture. Which finding requires the nurse's immediate attention?

• A. Lethargy
• B. Agitation
• C. Ataxia
• D. Hearing loss

Correct answer: A

Rationale: Lethargy is a critical finding that requires the nurse's immediate attention when a client with a recent skull fracture is readmitted to the hospital. It can indicate increased intracranial pressure or other serious complications such as hemorrhage or infection. Addressing lethargy promptly is crucial to prevent further deterioration. Agitation, ataxia, and hearing loss are important to assess but do not signify the same level of urgency as lethargy in this context.

2. 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.'

3. A community health nurse is developing a program to decrease the incidence of Type 2 diabetes in the community. Which of the following interventions should be included?

• A. distributing brochures on managing diabetes
• B. conducting exercise classes at the community center
• C. providing free glucose monitors
• D. offering dietary counseling sessions

Correct answer: B

Rationale: The correct answer is B: conducting exercise classes at the community center. Regular physical activity plays a crucial role in preventing Type 2 diabetes by helping to maintain a healthy weight, improve insulin sensitivity, and regulate blood sugar levels. Distributing brochures (choice A) may raise awareness but might not lead to significant behavior change. Providing free glucose monitors (choice C) focuses on monitoring rather than prevention. Offering dietary counseling sessions (choice D) is important but focusing solely on diet may not address the comprehensive approach needed to prevent Type 2 diabetes.

4. During which phase of the community organizing process are the leaders or groups given training to develop their knowledge, skills, and attitudes in managing their own programs?

• A. Sustenance and strengthening phase
• B. Pre-entry phase
• C. Organizing-building phase
• D. Entry phase

Correct answer: C

Rationale: The correct answer is C, the organizing-building phase. This phase involves providing training to leaders and groups to develop their knowledge, skills, and attitudes in managing their own programs. Choice A, the sustenance and strengthening phase, focuses more on maintaining and enhancing existing programs rather than training. Choice B, the pre-entry phase, occurs before actual organizing and training take place. Choice D, the entry phase, is about initiating the community organizing process, not specifically about training leaders and groups.

5. The nurse is assessing a client with portal hypertension. Which of the following findings would the nurse expect?

• A. Expiratory wheezes
• B. Blurred vision
• C. Ascites
• D. Dilated pupils

Correct answer: C

Rationale: Ascites is a common finding in clients with portal hypertension. Portal hypertension results in increased pressure in the portal vein, leading to the development of ascites, which is the accumulation of fluid in the abdominal cavity. Expiratory wheezes (Choice A) are associated with respiratory conditions. Blurred vision (Choice B) is more commonly linked to eye disorders or neurological issues. Dilated pupils (Choice D) can be related to neurological conditions or drug effects, but not specifically to portal hypertension.

Similar Questions