Nursing Elites

1. A female client makes routine visits to a neighborhood community health center. The nurse notes that this client often presents with facial bruising, particularly around the eyes. The nurse discusses prevention of domestic violence with the client even though the client does not admit to it. What level of prevention has the nurse applied in this situation?

• A. primary prevention
• B. secondary prevention
• C. tertiary prevention
• D. health promotion

Correct answer: A

Rationale: The nurse has applied primary prevention in this situation. Primary prevention involves efforts to prevent the occurrence of domestic violence before it starts, even if the client does not admit to the abuse. Secondary prevention focuses on early detection and intervention to reduce the harm caused by violence that is already occurring. Tertiary prevention involves actions taken to rehabilitate and support individuals who have experienced domestic violence. Health promotion encompasses a broader approach aimed at improving overall health and well-being, which may include education on domestic violence prevention but is not specific to this scenario.

2. The school nurse is developing an individualized healthcare plan for a student with type 1 diabetes. Which component is most important to include in the plan?

• A. a schedule for blood glucose monitoring
• B. a list of low-carbohydrate snacks
• C. a contact list of healthcare providers
• D. a log for recording insulin administration

Correct answer: A

Rationale: The correct answer is A: a schedule for blood glucose monitoring. Regular blood glucose monitoring is essential in managing type 1 diabetes as it helps in monitoring blood sugar levels, adjusting treatment plans, and preventing complications such as hypoglycemia or hyperglycemia. Choice B, a list of low-carbohydrate snacks, while important for managing blood sugar levels, is not as critical as consistent blood glucose monitoring. Choice C, a contact list of healthcare providers, though important for emergency situations, is not the most crucial component in managing daily care. Choice D, a log for recording insulin administration, is valuable for tracking insulin doses but does not directly address the immediate need for monitoring blood glucose levels.

3. A client who has been receiving chemotherapy for cancer has a platelet count of 20,000/mm3. Which intervention should the nurse include in the plan of care?

• A. Apply ice packs to bruised areas.
• B. Encourage frequent oral hygiene.
• C. Avoid invasive procedures.
• D. Place the client in a private room.

Correct answer: C

Rationale: The correct intervention for a client with a platelet count of 20,000/mm3 due to chemotherapy is to avoid invasive procedures. Chemotherapy can cause a decrease in platelet count, leading to an increased risk of bleeding. By avoiding invasive procedures, the nurse helps reduce the risk of bleeding complications. Applying ice packs to bruised areas (Choice A) may further increase the risk of bleeding due to the pressure and potential trauma to the skin. Encouraging frequent oral hygiene (Choice B) is important for overall health but does not directly address the risk of bleeding associated with a low platelet count. Placing the client in a private room (Choice D) is not directly related to managing the platelet count and risk of bleeding; it is more about privacy and infection control, which are important but not the priority in this scenario.

4. An elderly client with limited mobility reports feeling isolated and lonely. Which intervention should the nurse prioritize?

• A. Arrange for regular visits from a home health aide
• B. Suggest the client join a local senior center
• C. Refer the client to a support group for seniors
• D. Recommend that the client engage in a new hobby

Correct answer: B

Rationale: The correct answer is to suggest the client join a local senior center. Joining a local senior center provides the elderly client with opportunities for social interaction, engagement in activities, and access to support systems, which can significantly help alleviate feelings of isolation and loneliness. Regular visits from a home health aide (Choice A) may provide physical assistance but may not address the client's need for social connection. Referring the client to a support group for seniors (Choice C) is beneficial, but joining a senior center offers a wider range of activities and social opportunities. Recommending a new hobby (Choice D) may be helpful, but the priority should be addressing the client's immediate need for social interaction and support.

5. A client with a history of atrial fibrillation is receiving warfarin (Coumadin) therapy. Which laboratory result indicates that the therapy is effective?

• A. International normalized ratio (INR) of 1.0.
• B. Prothrombin time (PT) of 12 seconds.
• C. Partial thromboplastin time (PTT) of 60 seconds.
• D. International normalized ratio (INR) of 2.5.

Correct answer: D

Rationale: An International Normalized Ratio (INR) of 2.5 indicates that warfarin therapy is within the therapeutic range for a client with atrial fibrillation. A lower INR (such as 1.0) would suggest subtherapeutic levels, risking blood clots. Prothrombin time (PT) and partial thromboplastin time (PTT) are not specific to monitoring warfarin therapy.

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