Nursing Elites

1. A client has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?

• A. Droplet
• B. Contact
• C. Airborne
• D. Protective

Correct answer: A

Rationale: Pharyngeal diphtheria is transmitted via droplets, primarily through respiratory secretions. Therefore, droplet precautions are necessary to prevent the spread of the infection. Droplet precautions involve wearing a surgical mask, goggles, and a gown when within three feet of the client. Contact precautions are used for diseases transmitted by direct or indirect contact; airborne precautions are for diseases transmitted through airborne particles; protective precautions are not a standard precaution type.

2. The healthcare provider is assessing a client with a diagnosis of asthma. Which assessment finding would be most concerning?

• A. Wheezing
• B. Shortness of breath
• C. Use of accessory muscles
• D. Cough with sputum production

Correct answer: C

Rationale: The most concerning assessment finding in a client with asthma is the use of accessory muscles. This indicates that the client is working harder to breathe, which could signify respiratory distress. Wheezing, choice A, is a common finding in asthma and indicates narrowed airways but may not necessarily imply immediate distress. Shortness of breath, choice B, is also common in asthma but may not be as concerning as the use of accessory muscles. Cough with sputum production, choice D, can occur in asthma exacerbations but may not be as critical as signs of increased work of breathing like the use of accessory muscles.

3. When communicating with a client who is hearing impaired, what should the nurse do?

• A. Face the client and speak slowly
• B. Speak loudly and clearly
• C. Use written communication only
• D. Avoid using gestures or body language

Correct answer: A

Rationale: When communicating with a client who is hearing impaired, it is important to face the client and speak slowly. This helps the individual lip-read and understand the communication more easily. Speaking loudly can distort speech and make it harder for the person to understand. Written communication may not always be practical or accessible for the client, especially in real-time interactions. Gestures and body language can actually aid in communication by providing visual cues and context. Therefore, the best approach is to face the client, speak clearly at a moderate pace, and use gestures and body language to enhance understanding.

4. A client with a terminal illness is being educated by a healthcare provider about her decision to decline resuscitation in her living will. The client asks about the scenario of having difficulty breathing upon arrival at the emergency department.

• A. “We will apply oxygen through a tube in your nose.”
• B. “We will perform resuscitation efforts regardless of your wishes.”
• C. “You will receive only palliative care.”
• D. “We will ensure your comfort measures are met as per your advance directives.”

Correct answer: A

Rationale: Choice A is correct because applying oxygen through a tube in the nose provides comfort and aligns with the client's wishes for palliative care without resuscitation. This intervention can help alleviate breathing difficulties and maintain comfort without initiating full resuscitation efforts, respecting the client's decision. Choice B is incorrect as it goes against the client's expressed wish to decline resuscitation in her living will. Choice C is not the most appropriate response as it does not directly address the client's immediate concern of difficulty breathing and lacks specificity. Choice D, although focusing on comfort measures, is less specific than the correct choice A in addressing the client's immediate need for assistance with breathing.

5. The healthcare provider is caring for a client who has just been diagnosed with myasthenia gravis. Which symptom should the healthcare provider expect to observe?

• A. Muscle weakness
• B. Joint pain
• C. Vision changes
• D. Skin rash

Correct answer: A

Rationale: Muscle weakness is a hallmark symptom of myasthenia gravis, a neuromuscular disorder characterized by impaired neuromuscular transmission. This results in muscle weakness, particularly in skeletal muscles that control eye movements, facial expressions, chewing, swallowing, and speaking. Joint pain (Choice B) is not a typical symptom of myasthenia gravis and is more commonly associated with conditions like arthritis. Vision changes (Choice C) may occur in conditions affecting the eyes, but they are not specific to myasthenia gravis. Skin rash (Choice D) is also not a typical manifestation of myasthenia gravis. Therefore, the correct answer is muscle weakness (Choice A).

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