Nursing Elites

1. A nurse is taking the health history of an 85-year-old client. Which of the following physical findings is consistent with normal aging?

• A. Increase in subcutaneous fat.
• B. Diminished cough reflex.
• C. Long-term memory loss.
• D. Myopia.

Correct answer: B

Rationale: The correct answer is 'Diminished cough reflex.' Diminished cough reflex is a physical finding consistent with normal aging in older adults, which can increase the risk of aspiration and atelectasis. An increase in subcutaneous fat actually raises the risk of pressure ulcers. While long-term memory is typically preserved in aging unless affected by dementia, short-term memory often declines. Myopia (near-sightedness) is common in younger individuals, but presbyopia (far-sightedness) is more common with aging. Additionally, individuals with myopia may experience an improvement in vision as they age.

2. When discussing possible complications of pregnancy with a client, the nurse should explain that all of the following are symptoms of urinary tract infection (UTI). Which of the following is least indicative of UTI during pregnancy?

• A. low back pain
• B. urinary frequency
• C. GI distress
• D. malaise

Correct answer: B

Rationale: Urinary frequency is least indicative of UTI during pregnancy. It is a common minor discomfort of pregnancy caused by pressure of the growing uterus on the bladder. As the uterus rises in the second trimester, there are usually no problems. Frequency may return in the third trimester when the uterus drops into the pelvic cavity. UTI symptoms include low back pain, suprapubic discomfort, and malaise, and are confirmed by laboratory findings. Low back pain, GI distress, and malaise are more closely associated with UTI during pregnancy compared to urinary frequency.

3. While assessing a patient in the ICU, a nurse observes signs of a weak pulse, quick respiration, acetone breath, and nausea. Which of the following conditions is most likely occurring?

• A. Hypoglycemic patient
• B. Hyperglycemic patient
• C. Cardiac arrest
• D. End-stage renal failure

Correct answer: B

Rationale: The correct answer is a hyperglycemic patient. The signs described - weak pulse, quick respiration, acetone breath, and nausea - are indicative of hyperglycemia. A hypoglycemic patient would typically present with different signs such as pale skin, sweating, and confusion. Cardiac arrest would manifest with sudden loss of heart function and consciousness, not the signs described. End-stage renal failure would present with symptoms related to kidney dysfunction like edema, fatigue, and changes in urine output, which are not mentioned in the scenario.

4. While performing wound care to a donor skin graft site, the nurse notes some scabbing at the edges and a black collection of blood. What is the nurse's next action?

• A. Leave the scabbed area alone and apply extra ointment
• B. Notify the physician
• C. Gently remove the debris and re-dress the wound
• D. Apply skin softening lotion for 3 hours and then re-dress

Correct answer: C

Rationale: When the nurse notes scabbing at the edges and a black collection of blood, it indicates the presence of debris that needs to be addressed. Leaving the scabbed area alone and applying extra ointment may not address the underlying issue and could lead to complications. Notifying the physician is important in some cases, but immediate action is required to prevent infection in this situation. Gently removing the debris and re-dressing the wound is the correct course of action to promote healing and prevent complications.

5. A 93-year-old female with a history of Alzheimer's Disease gets admitted to an Alzheimer's unit. The patient has exhibited signs of increased confusion and limited stability with gait. Moreover, the patient is refusing to use a w/c. Which of the following is the most appropriate course of action for the nurse?

• A. Recommend the patient remain in her room at all times.
• B. Recommend family members bring pictures to the patient's room.
• C. Recommend a speech therapy consult to the doctor.
• D. Recommend the patient attempt to walk pushing the w/c for safety.

Correct answer: B

Rationale: For a 93-year-old female with Alzheimer's Disease exhibiting signs of increased confusion and limited stability with gait, recommending family members to bring pictures to the patient's room is the most appropriate course of action. Visual stimulation in the form of pictures may help decrease signs of confusion and provide comfort to the patient. Option A is incorrect as isolating the patient in her room at all times may worsen her condition by further limiting stimulation and interaction. Option C is incorrect as speech therapy may not directly address the current issues of confusion and gait instability. Option D is incorrect as pushing a wheelchair may not be safe for the patient if she is refusing to use it, potentially leading to falls or further distress.

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