Nursing Elites

1. During a dressing change, a healthcare professional observes granulation tissue in a client's wound. Which of the following findings should be documented?

• A. Stringy, white tissue
• B. Translucent, red tissue
• C. Soft, yellow tissue
• D. Thick, black tissue

Correct answer: B

Rationale: Granulation tissue is a hallmark of healing in wounds. It appears as translucent and red, indicating angiogenesis and the formation of new blood vessels in the wound bed. This tissue is vital for wound healing as it provides a scaffold for cell migration and promotes re-epithelialization. Choices A, C, and D do not describe granulation tissue accurately. Stringy, white tissue may suggest fibrin, soft, yellow tissue could indicate slough, and thick, black tissue may imply necrotic tissue, all of which are not synonymous with granulation tissue and do not signify the healing process.

2. The nurse notices that the mother of a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the LPN take?

• A. Directly address the child instead of the mother.
• B. Continue asking the mother questions about the child.
• C. Request another nurse to interview the mother now.
• D. Politely ask the mother to look at you when answering.

Correct answer: B

Rationale: In this scenario, the LPN should continue asking the mother questions about the child. The mother's behavior of looking at the floor may be a cultural practice, such as avoiding direct eye contact, which should be respected. By maintaining the conversation with the mother, the nurse acknowledges and respects her communication style, fostering trust and open dialogue. Option A is not the best choice as it may disregard the cultural context and the importance of the mother's input. Option C is unnecessary as the LPN can effectively handle the situation. Option D could be perceived as insensitive and may disrupt the rapport between the nurse and the mother.

3. A client with a diagnosis of hypertension is being assessed. Which symptom would be most concerning?

• A. Headache
• B. Blurred vision
• C. Dizziness
• D. Chest pain

Correct answer: D

Rationale: Chest pain in a client with hypertension is the most concerning symptom as it may indicate a myocardial infarction or other serious cardiac event related to hypertension. Immediate intervention is required to address potential life-threatening conditions. Headache, blurred vision, and dizziness are common symptoms associated with hypertension but are not typically indicative of an acute cardiac event requiring urgent attention.

4. When entering the room of an adult male, the nurse finds that the client is very anxious. Before providing care, what action should the nurse take?

• A. Divert the client’s attention
• B. Call for additional help from staff
• C. Document the planned action
• D. Re-assess the client's situation

Correct answer: D

Rationale: Re-assessing the client's situation before providing care is the most appropriate action in this scenario. By re-evaluating the client, the nurse can better understand the cause of the anxiety and tailor the care accordingly. Diverting the client's attention (Choice A) may not address the underlying issue causing anxiety. Calling for additional help (Choice B) is not the initial step required unless there is an urgent need. Documenting the planned action (Choice C) should come after reassessing the client to ensure accuracy and relevance.

5. A client with heart failure is being taught by a nurse on reducing daily sodium intake. Which factor is most crucial in determining the client’s ability to learn new dietary habits?

• A. The client's involvement in planning the change
• B. The cost of the dietary changes
• C. The availability of low-sodium foods
• D. The client’s previous dietary knowledge

Correct answer: D

Rationale: The client’s previous dietary knowledge is the most critical factor in determining the ability to learn new dietary habits. Understanding the client's existing dietary knowledge helps tailor the teaching to build upon what they already know. While client involvement in planning changes can increase adherence and motivation, the foundational knowledge is essential for effective learning. The cost of dietary changes and the availability of low-sodium foods are important considerations but not as crucial as the client's existing knowledge.

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