Nursing Elites

1. A nurse assisting with data collection of a client gathers both subjective and objective data. Which finding would the nurse document as subjective data?

• A. The client appears anxious.
• B. Blood pressure is 170/80 mm Hg.
• C. The client states that he has a rash.
• D. The client has diminished reflexes in the legs.

Correct answer: C

Rationale: Subjective data are information provided by the client about their symptoms, feelings, or experiences. In this case, the client reporting having a rash is subjective data because it is based on what the client says. Choices A, B, and D involve observations or measurements made by the nurse (anxious appearance, blood pressure, reflexes), which fall under objective data. Objective data are observable and measurable data obtained through physical examination, vital signs assessment, and laboratory tests.

2. The nurse is caring for a female client who has recently been diagnosed with cancer and will soon begin chemotherapy. Which of these statements would require additional follow-up and education?

• A. I will be most susceptible to an infection between 7 and 12 days after chemotherapy.
• B. I should try to get my annual teeth cleaning in before beginning chemotherapy.
• C. I should wait until all my hair falls out to purchase a wig.
• D. I should try to drink 8-10 glasses of water a day.

Correct answer: C

Rationale: This client is at risk for altered body image due to chemotherapy-induced hair loss. A wig can assist in coping with this change. It is advisable for the client to shop for a wig before hair loss occurs to better match color and style. Waiting until all hair falls out may lead to stress and limited options in finding a suitable wig. Choices A, B, and D are accurate. Understanding the timing of susceptibility to infection, maintaining oral health before chemotherapy, and staying hydrated are important aspects of care during chemotherapy. Therefore, the statement 'I should wait until all my hair falls out to purchase a wig' requires additional follow-up and education.

3. Which of the following foods should be avoided by clients who are prone to developing heartburn as a result of gastroesophageal reflux disease (GERD)?

• A. lettuce
• B. eggs
• C. chocolate
• D. butterscotch

Correct answer: C

Rationale: The correct answer is chocolate. Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure, leading to reflux and clinical symptoms of GERD. Lettuce, eggs, and butterscotch do not affect LES pressure and are less likely to trigger heartburn in individuals with GERD. Therefore, clients who are prone to developing heartburn due to GERD should avoid consuming chocolate to manage their symptoms effectively.

4. When teaching a woman about possible side effects of hormone replacement therapy, the nurse should include information about all of the following except:

• A. Hypoglycemia in diabetic women.
• B. The possible return of monthly menses when taking combination hormones.
• C. Increased risk of gallbladder disease.
• D. Increased risk of breast, cervical, and ovarian cancer with long-term use.

Correct answer: A

Rationale: The correct answer is 'Hypoglycemia in diabetic women.' When educating a woman about hormone replacement therapy, it is important to discuss the possible side effects. It is true that monthly menses might return when taking combination hormones, as the progestin can cause this. Additionally, there is an increased risk of gallbladder disease associated with hormone replacement therapy. Furthermore, long-term use of hormone replacement therapy is linked to an increased risk of breast, cervical, and ovarian cancer. However, hypoglycemia is not a common side effect of hormone replacement therapy, especially in diabetic women. In fact, estrogen can have a positive impact on glucose control in some cases, so hypoglycemia would not be a typical concern.

5. A pregnant client tells the nurse that she has a 2-year-old child at home and expresses concern about how the toddler will adapt to a newborn infant being brought into the home. Which statement is the most appropriate response for the nurse to make to the client?

• A. If your 2-year-old becomes angry or jealous, you should consider preparing the child for the new sibling rather than seeking psychological intervention.
• B. Don't worry; every 2-year-old may need time to adjust to a newborn sibling.
• C. Even though a 2-year-old may have little perception of time, any changes in sleeping arrangements for the newborn should be made several weeks before birth.
• D. A 2-year-old toddler focuses on exploring the environment, but it's important to prepare the child for the new sibling.

Correct answer: C

Rationale: The correct response by the nurse is, 'Even though a 2-year-old may have little perception of time, any changes in sleeping arrangements for the newborn should be made several weeks before birth.' Toddlers are generally unaware of the changes during pregnancy and may not understand the impending arrival of a new sibling. It is essential to prepare the child gradually for the new baby's arrival by making any necessary changes in sleeping arrangements beforehand. Expecting a young child to immediately welcome a new sibling without prior preparation is unrealistic. Option A is incorrect as suggesting psychological intervention prematurely is not appropriate. Option B is incorrect as assuming all 2-year-olds would immediately welcome a newborn is unrealistic. Option D is incorrect as dismissing the concerns without addressing the need for preparation is not appropriate in this situation.

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