Nursing Elites

1. A nurse assesses an 83-year-old female's venous ulcer for the second time that is located near the right medial malleolus. The wound is exhibiting purulent drainage, and the patient has limited mobility in her home. Which of the following is the best course of action?

• A. Encourage warm water soaks to the right foot.
• B. Notify the case manager of the purulent drainage.
• C. Determine the patient's pulse in the right ankle.
• D. Recommend increased activity to reduce the purulent drainage.

Correct answer: A

Rationale: The correct course of action is to encourage warm water soaks to the right foot. This can help promote wound healing and alleviate discomfort. Before recommending increased activity or notifying additional team members, it is crucial to assess arterial blood flow by determining the patient's pulse in the right ankle. Poor arterial blood flow could worsen the condition, making increased activity inappropriate. While notifying the case manager of purulent drainage is important, addressing the wound care directly should be the primary focus at this stage.

2. The schizophrenic client tells you that they are "Jesus"? and "there to save the world"?. They are reading from the Bible and warning others of hell and damnation. The whole unit is getting upset and several are beginning to cry. What should the nurse do at this time?

• A. Set limits and send the client to their room.
• B. Explain to the client that not all people are Christians.
• C. Remove the Bible from the client and explain that they are not "Jesus"?.
• D. Ask the client to share with the group how he knows that he is "Jesus"?.

Correct answer: A

Rationale: In this situation, the most appropriate action for the nurse to take is to set limits with the client and redirect them to their room. The client's behavior is disruptive and causing distress among others in the unit. Sending the client to their room allows them to cool down and prevents further agitation among other patients. Removing the client from the current environment can help de-escalate the situation. Asking the client to share how they know they are "Jesus"? (Choice D) may further agitate the situation and is not the immediate priority. Explaining to the client that not all people are Christians (Choice B) may not effectively address the disruptive behavior. Removing the Bible from the client (Choice C) without addressing the underlying issue may escalate the situation further.

3. A patient has recently been prescribed Zidovudine (Retrovir). The patient has AIDS. Which of the following side effects should the patient specifically watch out for?

• A. Weakness and SOB
• B. Fever and anemia
• C. Hypertension and SOB
• D. Fever and hypertension

Correct answer: B

Rationale: The correct answer is 'Fever and anemia.' Zidovudine (Retrovir) is known to cause anemia as a side effect due to its impact on the bone marrow. Fever is also a common side effect associated with Zidovudine use. Therefore, the patient should watch out for these specific side effects. Choice A (Weakness and SOB) is incorrect as shortness of breath (SOB) is not a commonly reported side effect of Zidovudine. Choice C (Hypertension and SOB) and Choice D (Fever and hypertension) are unrelated to the known side effects of Zidovudine, making them incorrect.

4. How can light therapy be effective?

• A. Improving weight problems.
• B. Assisting with allergies.
• C. Using in alternative medical treatments.
• D. Working with sleep patterns.

Correct answer: D

Rationale: Light therapy can be effective in treating problems associated with sleep patterns, stress, moods, jaundice in newborns, and seasonal affective disorders. While light therapy may have other potential benefits, such as improving mood or helping with seasonal affective disorders, the main focus and effectiveness of light therapy are commonly linked to regulating sleep patterns. Therefore, the correct answer is 'Working with sleep patterns.' Choices A, B, and C are incorrect as light therapy is not primarily used for overcoming weight problems, helping with allergies, or solely as an alternative medical treatment.

5. If a client is suffering from thyroid storm, the PN can expect to find on assessment:

• A. tachycardia and hyperthermia.
• B. bradycardia and hypothermia.
• C. a large goiter.
• D. a calm, quiet client

Correct answer: A

Rationale: In thyroid storm, there is an excess of thyroxine, leading to symptoms such as tachycardia (rapid heart rate) and hyperthermia (increased body temperature). Atrial fibrillation and palpitations are also commonly observed. Choices B and C are more indicative of hypothyroidism, where the thyroid is underactive, leading to bradycardia (slow heart rate), hypothermia (decreased body temperature), and the development of a large goiter. Choice D, a calm, quiet client, is unlikely in a thyroid storm where the individual would typically present with symptoms of agitation and restlessness due to the hypermetabolic state.

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