Nursing Elites

1. A client who had a hip replacement is being prepared for discharge. What should the nurse include in the discharge teaching to prevent hip dislocation?

• A. Avoid crossing your legs at the knees or ankles.
• B. Do not sleep on the side of the hip that was operated on.
• C. Sit in high chairs and keep your knees higher than your hips.
• D. Do not bend forward at the waist to pick up objects.

Correct answer: A

Rationale: The correct answer is A: 'Avoid crossing your legs at the knees or ankles.' Crossing legs at the knees or ankles can cause excessive stress on the new hip joint, leading to a risk of dislocation. Choice B is incorrect because sleeping on the side of the operated hip can also increase the risk of dislocation. Choice C is incorrect as sitting in low chairs with knees higher than hips is a recommended position to prevent hip dislocation. Choice D is incorrect because bending forward at the waist to pick up objects can strain the hip joint and increase the risk of dislocation.

2. What is the primary reason for applying sequential compression devices (SCDs) to a patient’s legs postoperatively?

• A. To prevent deep vein thrombosis (DVT)
• B. To promote wound healing
• C. To reduce postoperative pain
• D. To maintain body temperature

Correct answer: A

Rationale: The correct answer is A: To prevent deep vein thrombosis (DVT). Sequential compression devices (SCDs) are used postoperatively to prevent DVT by promoting blood circulation in the legs. This helps reduce the risk of blood clots forming in the deep veins of the legs. Choice B, to promote wound healing, is incorrect as SCDs are primarily used for circulatory purposes rather than wound healing. Choice C, to reduce postoperative pain, is incorrect as the primary purpose of SCDs is not pain management but rather prevention of DVT. Choice D, to maintain body temperature, is incorrect as SCDs are not designed for regulating body temperature but for preventing circulatory issues.

3. Which disorder is characterized by demyelination of neurons in the central nervous system?

• A. Multiple sclerosis
• B. Parkinson's disease
• C. Alzheimer's disease
• D. Huntington's disease

Correct answer: A

Rationale: Multiple sclerosis is the correct answer. It is an autoimmune disease that specifically targets and damages the myelin sheath surrounding neurons in the central nervous system. This demyelination disrupts the transmission of nerve signals and leads to a variety of neurological symptoms. Parkinson's disease (Choice B), Alzheimer's disease (Choice C), and Huntington's disease (Choice D) are neurodegenerative disorders that do not primarily involve demyelination of neurons in the CNS. Parkinson's disease is characterized by the loss of dopamine-producing neurons, Alzheimer's disease by the formation of plaques and tangles in the brain, and Huntington's disease by a genetic mutation affecting nerve cells.

4. A client post-mastectomy is concerned about the risk of lymphedema. What should the nurse include in the discharge instructions to minimize this risk?

• A. Wear compression garments on the affected arm.
• B. Avoid venipunctures and blood pressure measurements on the affected arm.
• C. Perform vigorous exercises to strengthen the affected arm.
• D. Keep the affected arm elevated at all times.

Correct answer: B

Rationale: To minimize the risk of lymphedema after a mastectomy, it is essential to instruct the client to avoid venipunctures and blood pressure measurements on the affected arm. These procedures can lead to trauma or impede lymphatic flow, increasing the risk of lymphedema. Wearing compression garments helps manage lymphedema but is not preventive. Performing vigorous exercises can strain the affected arm and increase the risk of lymphedema. Keeping the affected arm elevated at all times is unnecessary and not an effective preventive measure against lymphedema.

5. The home health nurse suspects elder abuse after observing fresh lacerations on the arms and legs of an older adult male client who lives with his daughter. Which action is most important for the nurse to take?

• A. Document the lacerations in the client's record
• B. Report findings to the supervisor for referral to adult protective services
• C. Ask the daughter who has been taking care of the client on a daily basis
• D. Apply dry dressings after cleansing the wounds

Correct answer: B

Rationale: In cases where elder abuse is suspected, the most critical action for the nurse to take is to report the findings to the supervisor for referral to adult protective services. This step is essential to protect the client from further harm and ensure their safety. Documenting the lacerations, as suggested in choice A, is important but not as urgent as ensuring immediate intervention by reporting the abuse. Asking the daughter for information, as in choice C, may not be effective if she is the abuser. Applying dressings, as in choice D, is a lower priority compared to taking action to address the suspected abuse.

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