Nursing Elites

1. A healthcare professional is reviewing the medical history of a client with dementia. Which of the following findings should be addressed immediately?

• A. Frequent episodes of wandering at night
• B. Restlessness and agitation
• C. Mild confusion during the day
• D. Incontinence

Correct answer: B

Rationale: Restlessness and agitation in clients with dementia should be addressed immediately as they can indicate underlying causes such as pain, discomfort, or unmet needs. Addressing these symptoms promptly can help prevent the escalation of behavioral issues and improve the client's quality of life. While frequent episodes of wandering at night, mild confusion during the day, and incontinence are also important issues to address in clients with dementia, restlessness and agitation usually require immediate attention to ensure the safety and well-being of the client.

2. A nurse in a long-term care facility is serving on the ethics committee, which is addressing a client care dilemma. Which of the following strategies will facilitate resolving the dilemma?

• A. Ensure client autonomy only
• B. Consider only medical benefits
• C. Ensure clear communication among the health care team
• D. Identify possible solutions

Correct answer: D

Rationale: In resolving ethical dilemmas, it is essential to identify possible solutions to address the client care dilemma effectively. Option A, 'Ensure client autonomy only,' is not comprehensive enough to resolve complex ethical issues. Option B, 'Consider only medical benefits,' overlooks other important factors beyond medical benefits that are involved in ethical decision-making. Option C, 'Ensure clear communication among the health care team,' is important but may not be sufficient on its own to resolve the ethical dilemma. Therefore, the most effective strategy among the given options is to identify possible solutions to navigate through the ethical dilemma.

3. A nurse is planning discharge teaching about cord care for the parents of a newborn. Which of the following instructions should the nurse plan to include in the teaching?

• A. Clean the base of the cord with hydrogen peroxide daily.
• B. The cord stump will fall off in 5 days.
• C. Contact the provider if the cord stump turns black.
• D. Keep the cord stump dry until it falls off.

Correct answer: D

Rationale: The correct answer is to keep the cord stump dry until it falls off. This is important to promote natural healing and prevent infection. Choice A is incorrect because cleaning the cord with hydrogen peroxide daily can actually delay healing and increase the risk of infection. Choice B is incorrect as the cord stump typically falls off within 1 to 3 weeks, not in 5 days. Choice C is incorrect because a cord stump turning black is a normal part of the healing process and does not necessarily indicate a problem requiring immediate provider contact.

4. A nurse in a long-term care facility is contributing to the plan of care for a client who has a new ostomy. Which of the following interventions should the nurse include?

• A. Change the appliance daily
• B. Clean the stoma once a day
• C. Avoid changing the appliance for a week
• D. Change the appliance twice each week

Correct answer: D

Rationale: The correct answer is to change the appliance twice each week. Changing the appliance too frequently can irritate the skin around the stoma, while not changing it often enough can lead to infection. Changing the appliance twice a week helps to maintain hygiene without causing irritation. Choices A, B, and C are incorrect because changing the appliance daily can cause irritation, cleaning the stoma once a day may not be sufficient for proper hygiene, and avoiding changing the appliance for a week can increase the risk of infection and skin breakdown.

5. A client reports difficulty having a bowel movement. What is the most appropriate intervention?

• A. Administer a laxative to relieve constipation
• B. Encourage the client to increase fiber intake
• C. Advise the client to rest in bed to avoid straining
• D. Encourage the client to exercise to stimulate bowel movement

Correct answer: B

Rationale: The correct answer is to encourage the client to increase fiber intake. Fiber helps promote regular bowel movements by adding bulk to the stool, making it easier to pass. Administering a laxative (Choice A) should not be the first-line intervention as it can lead to dependency and may not address the underlying cause of constipation. Advising the client to rest in bed (Choice C) may worsen constipation as physical activity helps stimulate bowel movements. Encouraging the client to exercise (Choice D) is beneficial, but increasing fiber intake is more directly related to improving bowel movements in this scenario.

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