Nursing Elites

1. A primipara with a breech presentation is in the transition phase of labor. The nurse visualizes the perineum and sees the umbilical cord extruding from the introitus. In which position should the nurse place the client?

• A. Supine with the foot of the bed raised.
• B. On the left side with legs elevated.
• C. On the right side with legs elevated.
• D. Prone with head elevated.

Correct answer: A

Rationale: In the scenario of a primipara with a breech presentation and a prolapsed umbilical cord, the nurse should place the client in the supine position with the foot of the bed raised (Trendelenburg position). This position helps alleviate gravitational pressure by the fetus on the cord, preventing compression and reducing the risk of cord prolapse complications. Placing the client on the left or right side with legs elevated or in a prone position with the head elevated would not be appropriate in this situation, as they do not effectively relieve the pressure on the umbilical cord.

2. The healthcare provider is developing a health education program for pregnant women on the importance of prenatal care. Which topic should be prioritized?

• A. the benefits of breastfeeding
• B. nutrition and weight gain during pregnancy
• C. the stages of fetal development
• D. signs and symptoms of preterm labor

Correct answer: D

Rationale: Prioritizing the discussion on signs and symptoms of preterm labor is essential as it empowers pregnant women to recognize warning signs promptly and seek medical assistance to prevent potential complications. Understanding preterm labor signs, such as abdominal cramping, pelvic pressure, or vaginal bleeding, can lead to early intervention and improve maternal and fetal outcomes. While topics like breastfeeding benefits, nutrition during pregnancy, and fetal development stages are important, identifying signs of preterm labor takes precedence due to its immediate impact on maternal and fetal well-being.

3. The nurse is conducting a process evaluation of a prevention education program for older adults who are at risk for substance abuse. Which data source provides the information the nurse needs to conduct this process evaluation?

• A. client's score on an alcohol screening instrument
• B. results of a urine drug and alcohol screen
• C. most recent community census data
• D. documentation of client education in the nursing record

Correct answer: D

Rationale: The correct answer is D. Documentation of client education in the nursing record provides information on the implementation and progress of the educational program, which is crucial for evaluating its process. Choices A and B focus on individual client assessment rather than program evaluation. Choice C, community census data, is not directly related to evaluating the process of the prevention education program for older adults at risk for substance abuse.

4. A public health nurse is planning a smoking cessation program for a local community. Which component is most important to include in the program?

• A. information on the health risks of smoking
• B. strategies for coping with withdrawal symptoms
• C. testimonials from former smokers
• D. distribution of nicotine replacement therapy

Correct answer: B

Rationale: The most important component to include in a smoking cessation program is strategies for coping with withdrawal symptoms. Withdrawal symptoms are a significant barrier to quitting smoking, and providing effective coping strategies can greatly increase the program's success. Choice A, providing information on the health risks of smoking, may be important but addressing withdrawal symptoms is more crucial. Testimonials from former smokers (Choice C) and distribution of nicotine replacement therapy (Choice D) are helpful but not as essential as addressing withdrawal symptoms directly.

5. The nurse is assessing a client who complains of weight loss, racing heart rate, and difficulty sleeping. The nurse determines the client has moist skin with fine hair, prominent eyes, lid retraction, and a staring expression. These findings are consistent with which disorder?

• A. Graves' disease.
• B. Cushing's syndrome.
• C. Addison's disease.
• D. Hypothyroidism.

Correct answer: A

Rationale: The correct answer is A, Graves' disease. The symptoms described in the client are classic manifestations of hyperthyroidism, which is commonly caused by Graves' disease, an autoimmune condition affecting the thyroid. Weight loss, racing heart rate, difficulty sleeping, moist skin with fine hair, prominent eyes, lid retraction, and a staring expression are all indicative of hyperthyroidism. Choice B, Cushing's syndrome, is characterized by weight gain, hypertension, and a rounded face due to excess cortisol. Choice C, Addison's disease, presents with symptoms such as weight loss, fatigue, and hyperpigmentation due to adrenal insufficiency. Choice D, hypothyroidism, typically features symptoms opposite to those described in the client, such as weight gain, bradycardia, and dry skin.

Similar Questions