Nursing Elites

1. At the time of the first dressing change, the client refuses to look at her mastectomy incision. The LPN tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence?

• A. It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel.
• B. Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery.
• C. It is OK if you don't want to talk about your surgery. I will be available when you are ready.
• D. I will ask a woman who has had a mastectomy to come by and share her experiences with you.

Correct answer: C

Rationale: In this situation, it's essential to acknowledge and respect the client's feelings and choices. Choice C is the most appropriate response as it validates the client's decision not to discuss the surgery while offering support and understanding. Giving the client space and letting them know you will be available when they are ready shows empathy and fosters trust. Choices A and B do not respect the client's autonomy and may come across as dismissive or pressuring. Choice D assumes the client needs advice from someone who has had a similar experience without considering the client's current emotional state and preferences.

2. The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that are associated with this problem include which of these?

• A. Lymphedema and nerve palsy
• B. Hearing loss and ataxia
• C. Headaches and vomiting
• D. Abdominal mass and weakness

Correct answer: D

Rationale: The correct answer is D: Abdominal mass and weakness. In neuroblastoma, the most common presenting signs are related to the mass effect of the tumor, leading to an abdominal mass and symptoms of weakness. Lymphedema and nerve palsy (Choice A) are not typically associated with neuroblastoma. Hearing loss and ataxia (Choice B) are more indicative of other conditions like neurofibromatosis or brain tumors. Headaches and vomiting (Choice C) are more commonly seen in conditions such as brain tumors or increased intracranial pressure, but they are not specific to neuroblastoma.

3. The patient diagnosed with diabetes is reporting severe foot pain due to corns and has been using oval corn pads to self-treat the corns. Which information will the nurse share with the patient?

• A. Corn pads are an adequate treatment and should be continued.
• B. The patient should avoid soaking the feet before using a pumice stone.
• C. The current self-treatment is likely impeding circulation to the toes.
• D. Tighter shoes would help compress the corns and make them smaller.

Correct answer: C

Rationale: The nurse should inform the patient that using oval corn pads can increase pressure on the toes and impede circulation, which may exacerbate foot problems in patients with diabetes. It is important to avoid practices that restrict blood flow to the feet, as poor circulation can lead to serious complications. Soaking the feet and using a pumice stone can be beneficial for corns, but in this case, the current self-treatment with corn pads is not recommended. Tighter shoes would further increase pressure on the corns and should be avoided. Therefore, the nurse should emphasize the importance of proper foot care and recommend alternative treatments to promote foot health and prevent complications.

4. A client has Clostridium difficile and is in contact isolation. Which of the following actions should the nurse take?

• A. Wear gloves when changing the client's gown.
• B. Use hand sanitizer after contact with the client.
• C. Wear a mask when entering the client's room.
• D. Clean the room with a disinfectant spray.

Correct answer: A

Rationale: The correct action for the nurse to take when caring for a client with Clostridium difficile in contact isolation is to wear gloves when changing the client's gown. Clostridium difficile is highly transmissible, and wearing gloves helps prevent the spread of the infection. Using hand sanitizer after contact with the client (Choice B) is not enough to prevent the transmission of C. difficile, as the spores can persist and spread. Wearing a mask when entering the client's room (Choice C) is not necessary for C. difficile transmission, which primarily occurs through contact with contaminated surfaces. Cleaning the room with a disinfectant spray (Choice D) is important, but wearing gloves during direct care is the priority to prevent the nurse from acquiring and spreading the infection.

5. A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?

• A. Protective environment
• B. Airborne precautions
• C. Droplet precautions
• D. Contact precautions

Correct answer: D

Rationale: The correct answer is D: Contact precautions. When a client has an abdominal wound with purulent drainage, contact precautions are necessary to prevent the spread of infection through direct contact. Protective environment precautions are used for immunocompromised clients, airborne precautions are for diseases transmitted by airborne particles, and droplet precautions are for diseases transmitted by respiratory droplets. In this case, the focus is on preventing direct contact transmission, making contact precautions the most appropriate choice. Protective environment, airborne, and droplet precautions are not indicated in this scenario because the primary concern is the direct contact transmission of pathogens through the wound drainage.

Similar Questions