Nursing Elites

1. A client with chronic congestive heart failure should be instructed to contact the home health nurse if which finding occurs?

• A. Weight gain of 2 pounds or more in a 48-hour period
• B. Urinating 4 to 5 times a day
• C. A significant decrease in appetite
• D. Appearance of non-pitting ankle edema

Correct answer: A

Rationale: A rapid weight gain of 2 pounds or more in a 48-hour period may indicate fluid retention and worsening heart failure, requiring prompt medical evaluation and intervention. This finding is crucial in managing chronic congestive heart failure as it signifies a potential exacerbation of the condition. Choices B, C, and D are less concerning in this context. Urinating 4 to 5 times a day is within the normal range for most individuals and may not be directly related to heart failure. A significant decrease in appetite may be due to various factors and might not be an immediate cause for concern in heart failure patients. The appearance of non-pitting ankle edema, although related to heart failure, is a more chronic and less urgent symptom when compared to a rapid weight gain, which requires immediate attention.

2. The nurse is assigned to a client with Parkinson's disease. Which findings would the nurse anticipate?

• A. Non-intention tremors and urgency with voiding
• B. Echolalia and a shuffling gait
• C. Muscle spasm and a bent-over posture
• D. Intention tremor and jerky movement of the elbows

Correct answer: B

Rationale: The correct answer is B. Echolalia (repeating others' words) and a shuffling gait are common symptoms of Parkinson's disease. These symptoms result from the degeneration of the basal ganglia in the brain that controls movement and speech. Choice A is incorrect because non-intention tremors are not typically associated with Parkinson's disease. Choice C is incorrect as muscle spasm and a bent-over posture are not classic manifestations of Parkinson's disease. Choice D is incorrect since intention tremors and jerky movement of the elbows are not characteristic of Parkinson's disease.

3. When teaching a responsible family member how to perform a certain procedure for the patient, what is the best approach?

• A. Perform all these steps
• B. Arrange for the practice of the procedure
• C. Describe the procedure
• D. Demonstrate the procedure

Correct answer: D

Rationale: The best approach when teaching a responsible family member a procedure for the patient is to demonstrate the procedure. By demonstrating, the family member can visually see how it is done, making it easier for them to understand and replicate. This hands-on approach is more effective than just describing the procedure (choice C) or arranging for practice (choice B) without a visual demonstration. Performing all the steps (choice A) may not be practical or necessary when the goal is to teach someone else how to do it.

4. The nurse is caring for a 75-year-old client in congestive heart failure. Which finding suggests that digitalis levels should be reviewed?

• A. Extreme fatigue
• B. Increased appetite
• C. Intense itching
• D. Constipation

Correct answer: A

Rationale: Extreme fatigue can be a sign of digitalis toxicity, especially in older adults, and warrants a review of the client's medication levels and potential adjustment. Increased appetite, intense itching, and constipation are not typically associated with digitalis toxicity and do not directly indicate a need for a review of digitalis levels.

5. A client with terminal cancer is experiencing severe pain. The nurse plans to implement which of the following pain management strategies?

• A. Administer analgesics on a fixed schedule
• B. Administer analgesics only when the client requests
• C. Use non-pharmacological methods only
• D. Increase the dose of analgesics when the client complains of pain

Correct answer: A

Rationale: Administering analgesics on a fixed schedule is the most appropriate pain management strategy for a client with terminal cancer experiencing severe pain. This approach ensures consistent pain control and helps prevent breakthrough pain. Administering analgesics only when the client requests (Choice B) may lead to uncontrolled pain as the client may delay requesting medication until the pain becomes unbearable. Using non-pharmacological methods only (Choice C) may not provide adequate pain relief for a client experiencing severe pain. Increasing the dose of analgesics when the client complains of pain (Choice D) may result in inconsistent pain control and could lead to potential overdose or adverse effects.

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