Nursing Elites

1. A client is receiving education on cholesterol. Which of the following statements from the client indicates the need for further teaching?

• A. I would like my HDL levels to be over 50.
• B. It is better for me to have high HDL levels and low LDL levels.
• C. It is better for me to have high LDL levels and low HDL levels.
• D. My goal is to get my total cholesterol below 200.

Correct answer: C

Rationale: The correct answer is, 'It is better for me to have high LDL levels and low HDL levels.' This statement indicates a need for further teaching because high LDL levels contribute to atherosclerosis, while high HDL levels can protect against heart disease. The client should understand the importance of lowering LDL levels and increasing HDL levels to maintain good heart health. Choice A is correct as desiring HDL levels over 50 is a positive goal. Choice B is correct as it reflects the ideal scenario of high HDL and low LDL levels. Choice D is correct as a total cholesterol below 200 is a common goal for heart health. Therefore, Choice C is incorrect as it suggests an opposite and unhealthy relationship between LDL and HDL levels.

2. Which of the following clients have barriers to accessing healthcare?

• A. A 36-year-old client who must use a wheelchair for mobility
• B. A 44-year-old client who is visiting the United States on a visa from India
• C. An 81-year-old client who is unable to drive
• D. All of the above

Correct answer: D

Rationale: All of the provided clients have barriers to accessing healthcare. Clients with physical limitations, such as the 36-year-old client using a wheelchair, may face challenges in mobility and accessing healthcare facilities. The 44-year-old client from India visiting the United States on a visa may encounter barriers related to language, cultural differences, or insurance coverage. The 81-year-old client who is unable to drive may struggle with transportation to healthcare appointments. Therefore, all three clients face different barriers to accessing healthcare, making 'All of the above' the correct answer.

3. A client with schizophrenia seems to stop focusing during a conversation with a nurse and begins looking at the ceiling and talking to themselves. Which of the following actions should the nurse take?

• A. Stop the interview at this point and resume later when the client is better able to concentrate
• B. Ask the client, 'Are you seeing something on the ceiling?'
• C. Tell the client, 'You seem to be looking at something on the ceiling. I see something there, too.'
• D. Continue the interview without commenting on the client's behavior

Correct answer: B

Rationale: When a client with schizophrenia experiences a break in reality like staring at the ceiling and talking to themselves, the nurse should ask directly about the hallucination, as stated in choice B. By doing so, the nurse can assess the situation, identify the client's needs, and evaluate any potential risk for injury. Choices A, C, and D are incorrect. Stopping the interview (choice A) may not address the immediate concern of the hallucination. Providing false reassurance (choice C) or ignoring the behavior (choice D) does not actively address the client's altered perception of reality.

4. While caring for a client who has just come from surgery and is in the recovery room with an endotracheal tube in place, the nurse deflates the cuff on the tube and removes it. The client sits up in bed, grasps his throat, and begins to make wheezing sounds. Which of the following conditions is the most likely cause of this situation?

• A. The client is choking on part of the tube
• B. The client has anxiety
• C. The client is having a laryngospasm
• D. The client is having a normal response from anesthesia

Correct answer: D

Rationale: After surgery, some clients may experience a laryngospasm during emergence from anesthesia. A laryngospasm can lead to the closure of the laryngeal opening due to spasm of the vocal cords. In this scenario, the client's symptoms of wheezing and throat grasping are indicative of a laryngospasm rather than choking on the tube, anxiety, or a normal response from anesthesia. The nurse should act promptly to open the airway to aid breathing and consider administering muscle relaxants as necessary.

5. A client returns from surgery after having a colon resection. The nurse is performing an assessment and notes the wound edges have separated. This condition is called:

• A. Evisceration
• B. Hematoma
• C. Dehiscence
• D. Granulation

Correct answer: C

Rationale: Wound dehiscence occurs when the edges of a wound pull apart. The condition may occur following a surgical procedure if the sutures were deficient. Wound dehiscence may also occur following a wound infection or in cases where a client significantly stretches or overuses the associated tissues. Evisceration refers to the protrusion of internal organs through an open wound. Hematoma is a localized collection of blood outside the blood vessels. Granulation is the formation of new connective tissue and tiny blood vessels on the surface of a wound during the healing process.

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