Nursing Elites

1. A nurse assesses a client who has a history of heart failure. Which question should the nurse ask to assess the extent of the client's heart failure?

• A. Do you have trouble breathing or chest pain?
• B. Are you able to walk upstairs without fatigue?
• C. Do you awake with breathlessness during the night?
• D. Do you have new-onset heaviness in your legs?

Correct answer: B

Rationale: Clients with a history of heart failure generally have negative findings, such as shortness of breath. The nurse needs to determine whether the client's activity is the same or worse, or whether the client identifies a decrease in activity level. Trouble breathing, chest pain, breathlessness at night & peripheral edema are symptoms of heart failure, but do not provide data that can determine the extent of the client's heart failure.

2. When interviewing a client recently diagnosed with lung cancer and having a 60-pack-year smoking history, what is the most important action for the nurse to take?

• A. Educate the client about the importance of quitting smoking to halt cancer progression.
• B. Encourage the client to disclose both tobacco and marijuana use openly.
• C. Maintain a nonjudgmental attitude to promote honest communication with the client.
• D. Provide realistic information about cancer treatment and prognosis without giving false hope.

Correct answer: C

Rationale: Maintaining a nonjudgmental attitude during the interview is crucial to create a safe environment where the client feels comfortable and open about disclosing their smoking history and other relevant information. This approach helps establish trust and facilitates an honest conversation which is essential for providing appropriate care and support to the client.

3. During an assessment, a client with a long history of smoking and suspected laryngeal cancer will most likely report which early manifestation?

• A. Dysphagia
• B. Hoarseness
• C. Dyspnea
• D. Weight loss

Correct answer: B

Rationale: In clients with laryngeal cancer, hoarseness is often one of the earliest manifestations due to vocal cord involvement. The irritation and inflammation caused by the tumor affect the vocal cords, leading to changes in voice quality. Dysphagia (choice A) typically occurs later as the tumor grows and interferes with swallowing. Dyspnea (choice C) and weight loss (choice D) may occur as the cancer progresses, but hoarseness is usually among the first signs to manifest in laryngeal cancer.

4. A client with deep vein thrombosis (DVT) is receiving heparin therapy. What is the priority assessment for the nurse?

• A. Monitoring blood pressure
• B. Checking the activated partial thromboplastin time (aPTT)
• C. Assessing for signs of bleeding
• D. Measuring calf circumference

Correct answer: C

Rationale: Assessing for signs of bleeding is the priority when caring for a client with deep vein thrombosis (DVT) receiving heparin therapy. Heparin therapy increases the risk of bleeding complications, so monitoring for signs of bleeding is crucial to ensure patient safety and timely intervention if needed.

5. A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best?

• A. Do you have trouble affording your medications?
• B. Most people with hypertension do not have symptoms.
• C. You are lucky; most people get severe morning headaches.
• D. You need to take your medicine or you will get kidney failure.

Correct answer: B

Rationale: Most people with hypertension are asymptomatic, although a small percentage do have symptoms such as headache. The nurse should explain this to the client. Asking about paying for medications is not related because the client has already admitted nonadherence. Threatening the client with possible complications will not increase compliance.

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