Nursing Elites

1. A client with lupus experience Raynaud's phenomenon. What should the nurse include when providing client education about this?

• A. In order to avoid flare-ups of Raynaud's, ensure you wear gloves in winter.'
• B. In order to avoid flare-ups of Raynaud's, ensure you brush your teeth for 2 minutes.'
• C. In order to avoid flare-ups of Raynaud's, ensure to keep cool.'
• D. In order to avoid flare-ups of Raynaud's, ensure you wear sunscreen.'

Correct answer: A

Rationale:

2. What is a negative effect of immobility on the cardiovascular system?

• A. Increased high density lipoprotein
• B. Increased circulation
• C. Increased pumping action of the heart
• D. Venous stasis

Correct answer: D

Rationale: Venous stasis is a negative effect of immobility on the cardiovascular system. Immobility can lead to blood pooling in the veins due to lack of movement, increasing the risk of blood clots. Choices A, B, and C are incorrect because immobility does not lead to an increase in high density lipoprotein, circulation, or the pumping action of the heart.

3. The client is at risk for impaired skin integrity related to the need for several weeks of bedrest. The nurse evaluates the client after 1 week and finds skin integrity is not impaired. In evaluating the plan of care, what is the nurse's best action?

• A. Remove the nursing diagnosis in the plan of care since it has not occurred
• B. Change the nursing diagnosis in plan of care to impaired mobility
• C. Modify the nursing diagnosis in plan of care to impaired skin integrity
• D. Keep the nursing diagnosis in the plan of care the same since the risk factors are still present

Correct answer: D

Rationale:

4. A goal for a client with impaired mobility is to prevent skin breakdown. What nursing intervention would best help the client meet this goal?

• A. Assist the client to orthopneic position
• B. Offer the client a bedpan for toileting
• C. Offer a protein-rich diet
• D. Turn the client every 2 hours

Correct answer: D

Rationale:

5. What is the condition called when the client's pupils are different sizes and have been this way since childhood?

• A. Exophthalmos
• B. Anisocoria
• C. Strabismus
• D. Scleral edema

Correct answer: B

Rationale: Anisocoria is the correct answer. Anisocoria is the condition of having pupils of different sizes. Exophthalmos refers to abnormal protrusion of the eyeball, not pupil size difference. Strabismus is a condition where the eyes are not properly aligned with each other. Scleral edema is swelling of the sclera, the white part of the eye, and not related to differing pupil sizes.

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