Nursing Elites

1. During the care of a client with Legionnaire's disease, which finding would require the nurse's immediate attention?

• A. Pleuritic pain on inspiration
• B. Dry mucus membranes in the mouth
• C. A decrease in respiratory rate from 34 to 24
• D. Decrease in chest wall expansion

Correct answer: D

Rationale: A decrease in chest wall expansion suggests that the client may be experiencing a serious complication, such as worsening pneumonia or respiratory failure, requiring immediate medical attention. This finding indicates a potential decrease in lung function, which could lead to respiratory distress. Pleuritic pain on inspiration may be related to the disease process but does not indicate an immediate need for intervention. Dry mucus membranes in the mouth may require attention but are not as critical as a decrease in chest wall expansion. A decrease in respiratory rate could be concerning but is not as urgent as a decrease in chest wall expansion, which directly impacts respiratory function.

2. An 82-year-old client is prescribed eye drops for the treatment of glaucoma. What assessment is needed before the nurse begins teaching proper administration of the medication?

• A. Determine the client's manual dexterity
• B. The client’s manual dexterity
• C. Proximity to health care services
• D. Ability to use visual assistive devices

Correct answer: B

Rationale: Assessing the client’s manual dexterity is crucial before teaching the administration of eye drops. Manual dexterity is essential for the proper instillation of eye drops. If the client has limited manual dexterity, alternative methods of administration may be necessary. The other choices, such as determining third-party payment plan, proximity to health care services, and ability to use visual assistive devices, are not directly related to the immediate need for assessing manual dexterity for the proper administration of eye drops.

3. The nurse is caring for a 4-year-old child with a greenstick fracture. In explaining this type of fracture to the parents, the best response by the nurse should be that

• A. A child's bone is more flexible and can be bent 45 degrees before breaking
• B. Bones of children are more porous than adults and often have incomplete breaks
• C. Compression of porous bones produces a buckle or torus type break
• D. Bone fragments often remain attached by a periosteal hinge

Correct answer: B

Rationale: The correct answer is B. Greenstick fractures are common in children because their bones are softer and more porous than adult bones, leading to incomplete breaks when force is applied. Choice A is incorrect as greenstick fractures are not due to bone flexibility but rather the porous nature of children's bones. Choice C is incorrect as it describes a buckle or torus type break, which is not characteristic of a greenstick fracture. Choice D is incorrect as greenstick fractures do not involve bone fragments remaining attached by a periosteal hinge.

4. The process by which an individual gains knowledge and skills to improve their health and well-being is known as:

• A. Health literacy
• B. Health education
• C. Health promotion
• D. Health behavior

Correct answer: B

Rationale: The correct answer is B: Health education. Health education is the process through which individuals acquire knowledge and skills to enhance their health and well-being. Health literacy (choice A) refers to the ability to understand and use health information, but it is not the same as the process of gaining knowledge and skills. Health promotion (choice C) involves advocating for health and implementing interventions to improve health outcomes, rather than the individual learning process. Health behavior (choice D) pertains to the actions individuals take regarding their health, not specifically the process of gaining knowledge and skills.

5. In planning the use of resources for secondary prevention in a community clinic serving migrant families, which activity should be the priority?

• A. Skin testing for tuberculosis.
• B. Glucose monitoring for diabetes.
• C. Blood work for cardiovascular disease.
• D. Height and weight for altered nutrition.

Correct answer: A

Rationale: The correct answer is A: Skin testing for tuberculosis. In a community clinic serving migrant families, tuberculosis is a significant health concern due to close living conditions and potential exposure during migration. Skin testing for tuberculosis is crucial for secondary prevention as it helps in early detection and prevention of the spread of the disease within the community. Choices B, C, and D are important health screenings but may not be the priority in this specific population where tuberculosis poses a higher risk.

Similar Questions