Nursing Elites

1. An older adult who recently began self-administration of insulin calls the nurse daily to review the steps that should be taken when giving an injection. The nurse has assessed the client's skills during two previous office visits and knows that the client is capable of giving the daily injection. Which response by the nurse is likely to be most helpful in encouraging the client to assume total responsibility for the daily injections?

• A. I know you are capable of giving yourself the insulin.
• B. Giving yourself the injection seems to make you nervous.
• C. When I watched you give yourself the injection, you did it correctly.
• D. Tell me what you want me to do to help you give yourself the injection at home.

Correct answer: C

Rationale: Choice C is the correct answer because focusing on the client's demonstrated ability to self-administer the injection is likely to reinforce his level of competence without sounding punitive. By acknowledging the client's correct performance during the self-injection, the nurse can boost the client's confidence, encouraging him to assume total responsibility for the daily injections. Choices A, B, and D do not directly highlight the client's competence in self-administration, which may not be as effective in promoting independent self-care.

2. When a male client mentions his foot is hurting while watching TV with his wife, how should the nurse respond?

• A. Ask him to rate his pain on a scale of 1 to 10.
• B. Encourage him to wait until bedtime for the pill to help him sleep.
• C. Attend to an acutely ill client's needs first as the client is laughing.
• D. Instruct him in the use of deep breathing exercises for pain control.

Correct answer: A

Rationale: The correct response is to ask the client to rate his pain on a scale of 1 to 10. This helps the nurse assess the intensity of the pain and determine the appropriate pain medication. Encouraging him to wait or attend to another client's needs first are incorrect because pain management should be addressed promptly. Instructing on deep breathing exercises may be helpful but is not the initial step in addressing acute pain.

3. The client is being taught how to perform active range of motion (ROM) exercises. To exercise the hinge joints, which action should the client be instructed to perform?

• A. Tilt the pelvis forwards and backwards
• B. Bend the arm by flexing the ulnar to the humerus
• C. Turn the head to the right and left
• D. Extend the arm at the side and rotate it in circles

Correct answer: B

Rationale: Hinge joints, like the elbow, primarily allow movement in one direction, in this case, bending the arm. The correct action to exercise hinge joints is to bend the arm by flexing the ulnar to the humerus. This movement specifically targets the hinge joint and promotes its range of motion. Choices A, C, and D involve movements that do not specifically target hinge joints. Tilt the pelvis involves the ball-and-socket joints of the hip, turning the head involves the pivot joint of the neck, and extending the arm and rotating it in circles involve multiple joints including ball-and-socket and pivot joints.

4. A client with a diagnosis of hyperthyroidism is being discharged. Which instruction should the nurse include in the discharge teaching?

• A. Avoid foods high in iodine.
• B. Take your medication with meals.
• C. Monitor your weight daily.
• D. Decrease your daily fluid intake.

Correct answer: A

Rationale: The correct answer is A: 'Avoid foods high in iodine.' Clients with hyperthyroidism should avoid foods high in iodine to prevent exacerbation of their condition. Iodine is an essential component in thyroid hormone production, and excessive iodine intake can worsen hyperthyroidism symptoms. Taking medication with meals (B) can interfere with the absorption of certain thyroid medications. Monitoring weight daily (C) is more relevant for conditions that may lead to weight changes like hypothyroidism. Decreasing fluid intake (D) is not a standard recommendation for hyperthyroidism unless specifically indicated by the healthcare provider.

5. The UAP is positioning a newly admitted client with a seizure disorder in a supine position. The UAP is placing soft pillows along the side rails. What action should the nurse take?

• A. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows
• B. Ensure that the UAP has placed pillows effectively to protect the client
• C. Ask the UAP to use some pillows to prop the client in a side-lying position
• D. Assume responsibility for placing the pillows while the UAP completes another task

Correct answer: A

Rationale: To prevent the risk of suffocation, soft blankets are preferred over pillows for padding side rails in clients with seizure disorders. Pillows can pose a suffocation hazard, especially during a seizure episode when the client's movements may be uncontrolled. Instructing the UAP to use soft blankets instead of pillows is crucial for ensuring the client's safety. Choice B is incorrect because pillows can be hazardous during a seizure. Choice C is incorrect as side-lying position may not be appropriate for a client with a seizure disorder. Choice D is incorrect as it does not address the safety concern related to using pillows.

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