Nursing Elites

1. A healthcare provider is assessing the pain level of a client who has dementia and difficulty communicating. Which pain assessment technique should the healthcare provider use?

• A. Verbal self-report
• B. Pain scale
• C. Behavioral indicators
• D. Observing facial expressions

Correct answer: C

Rationale: In clients with dementia and difficulty communicating, using behavioral indicators such as agitation and restlessness is more reliable for assessing pain than relying on verbal self-report, pain scales, or observing facial expressions. Verbal self-report may not be possible due to communication challenges, pain scales may be difficult for the client to comprehend, and observing facial expressions alone may not provide a comprehensive assessment of pain in individuals with dementia.

2. A client with a new diagnosis of diabetes mellitus is being taught about foot care. What instruction should the nurse include?

• A. Apply lotion between the toes after bathing
• B. Wear shoes at all times
• C. Cut toenails in a rounded shape
• D. Inspect the feet weekly

Correct answer: B

Rationale: The correct answer is to wear shoes at all times. This instruction is vital for clients with diabetes mellitus as it helps protect the feet and reduces the risk of injury. Option A is incorrect as applying lotion between the toes can increase moisture and the risk of fungal infections. Option C is incorrect as cutting toenails in a rounded shape may lead to ingrown toenails. Option D is also incorrect as inspecting the feet weekly is not sufficient for proper foot care in clients with diabetes mellitus.

3. A nurse is sitting with the partner of a client who recently died. Which action should the nurse take to facilitate mourning?

• A. Avoid discussing the deceased
• B. Encourage the partner to ask for help when needed
• C. Suggest bereavement counseling
• D. Offer to contact family members

Correct answer: B

Rationale: Encouraging the partner to ask for help when needed is the most appropriate action in this scenario as it promotes healthy coping mechanisms and support during the mourning process. This approach empowers the individual to seek assistance when required, fostering a sense of control and acknowledging the partner's autonomy in dealing with their grief. Avoiding discussing the deceased (Choice A) may hinder the grieving process by suppressing emotions and preventing the partner from expressing their feelings. While suggesting bereavement counseling (Choice C) is important, the immediate support and encouragement to seek help when needed are crucial. Offering to contact family members (Choice D) may not be the most effective step at this stage, as the focus should be on empowering the partner to cope and seek help on their terms.

4. A healthcare professional is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea. What finding should the healthcare professional expect?

• A. Decreased respiratory rate
• B. Flushing of the skin
• C. Flaring of the nostrils
• D. Productive cough

Correct answer: C

Rationale: Flaring of the nostrils is a sign of increased respiratory effort, which is common in clients with COPD experiencing dyspnea. Choices A, B, and D are incorrect. A decreased respiratory rate is not expected in a client with COPD experiencing dyspnea, as they often have an increased respiratory rate. Flushing of the skin is not a typical finding associated with COPD or dyspnea. While a productive cough can be seen in COPD, it is not specifically related to the increased respiratory effort seen with dyspnea.

5. A nurse is assessing a client who reports a burning sensation at the site of a peripheral IV. The site is red and swollen. What is the nurse's priority action?

• A. Apply a cold compress
• B. Discontinue the IV line
• C. Elevate the limb
• D. Increase the IV flow rate

Correct answer: B

Rationale: The correct answer is to discontinue the IV line. The client's symptoms of a burning sensation, redness, and swelling at the IV site indicate phlebitis, which is inflammation of the vein. The priority action in this situation is to remove the source of irritation, which is the IV line, to prevent further complications such as infection or thrombosis. Applying a cold compress may provide temporary relief but does not address the underlying issue. Elevating the limb is not the priority in this case. Increasing the IV flow rate can worsen the phlebitis by causing further irritation to the vein.

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