Nursing Elites

1. An LPN is caring for a primarily bedridden client. Which finding should be of least concern?

• A. swollen feet
• B. brown discoloration above the ankles
• C. leg pain
• D. capillary refill time of 3 seconds on the big toe

Correct answer: D

Rationale: The correct answer is the capillary refill time of 3 seconds on the big toe. A capillary refill time longer than three seconds may indicate inadequate blood flow. Swollen feet, brown discoloration above the ankles, and leg pain are all signs of venous insufficiency to the lower extremities. These findings can suggest circulation issues and require further assessment and intervention. Therefore, they should be of more concern compared to the capillary refill time of 3 seconds on the big toe, which is within the normal range of 2-3 seconds.

2. A client with cirrhosis of the liver presents with ascites. The physician is to perform a paracentesis. For safety, the nurse should ask the client to:

• A. drink 1000 cc of fluid prior to the procedure to aid in fluid loss.
• B. eat foods low in fat.
• C. empty his bladder prior to the procedure.
• D. assume the prone position.

Correct answer: C

Rationale: When performing a paracentesis, the client must be sitting up to allow the fluid to settle in the lower abdomen. To prevent trauma to the bladder while inserting a needle to aspirate the fluid, the bladder must be empty. Choice A is incorrect as excessive fluid intake can make the procedure more difficult due to increased abdominal distension. Choice B is unrelated to the procedure of paracentesis. Choice D is incorrect as the client should be sitting up, not in the prone position, during the procedure.

3. Which of the following statements to the client's family would be appropriate when preparing to provide postmortem care to the client?

• A. "You will not be allowed to see your family member after the postmortem care is performed."?
• B. "I am not able to assist you, but we can call pastoral care if you need any comfort."?
• C. "Unfortunately, we are not allowed to incorporate any cultural practices in my preparations."?
• D. "I will be ensuring that your family member is properly identified before they are transported."?

Correct answer: D

Rationale: The correct statement when preparing to provide postmortem care to the client's family is to assure them that the family member will be properly identified before transportation. This is crucial in ensuring the correct individual is being handled respectfully. Choices A, B, and C are incorrect as they do not address the essential aspect of ensuring the proper identification of the deceased before transportation. It is important to allow the family to see their loved one after postmortem care and, if possible, incorporate any cultural practices. Providing comfort and support to the family during this difficult time is also essential in delivering holistic care.

4. The laws enacted by states to provide immunity from liability to persons who provide emergency care at an accident scene are called:

• A. Good Samaritan laws.
• B. HIPAA.
• C. Patient Self-Determination Act (PSDA).
• D. OBRA.

Correct answer: A

Rationale: The correct answer is Good Samaritan laws. These laws protect individuals who provide voluntary emergency care from being held liable for any unintended injury or harm that may occur during the care. Good Samaritan laws encourage individuals to assist in emergencies without fear of legal repercussions. HIPAA, on the other hand, focuses on safeguarding patient information and privacy, ensuring confidentiality. The Patient Self-Determination Act (PSDA) pertains to a patient's rights to make decisions about their medical treatment and advance directives. OBRA, enacted in the late 1980s, aims to improve the quality of care in nursing homes and enhance residents' quality of life, focusing on nursing home reform and standards, which is not directly related to immunity for emergency care providers.

5. Which is an appropriate outcome for the nursing diagnosis of Body Image Disturbance for a client with anorexia nervosa?

• A. The client verbalizes knowledge of a maintenance diet.
• B. The client demonstrates assertiveness with family.
• C. The client verbalizes her body size accurately.
• D. The client demonstrates control of obsessive behaviors.

Correct answer: C

Rationale: The correct answer is 'The client verbalizes her body size accurately.' For clients with anorexia nervosa, body image disturbance is a common issue where they perceive themselves inaccurately. Verbalizing her body size accurately indicates progress towards correcting this distorted self-perception. Choices A, B, and D are incorrect because they do not directly address the distorted body image perception seen in clients with anorexia nervosa. Choice A focuses on knowledge of a maintenance diet, which is unrelated to body image perception. Choice B involves assertiveness with family, which is more related to family dynamics. Choice D addresses control of obsessive behaviors, which is not directly related to correcting the distorted body image perception.

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