Nursing Elites

1. When a sequence of repeated weights is necessary, the healthcare provider should aim to weigh the patient at the same time of day and with consistent clothing. Using a standardized balance or electronic standing scale is recommended for accurate measurements. The patient should remove shoes and heavy outer clothing. It is not required for the patient to always be weighed in undergarments. What is the most appropriate indicator of the patient's overall well-being?

• A. General health
• B. Genetic makeup
• C. Nutritional status
• D. Activity and exercise patterns

Correct answer: A

Rationale: Weight measurements are essential to assess general health, particularly in monitoring growth patterns. Height and weight recordings are crucial indicators of overall well-being, reflecting the individual's health status. Genetic makeup does not change with weight fluctuations, making it an inappropriate indicator. Nutritional status and activity levels can influence weight but are not as comprehensive as general health in reflecting overall well-being.

2. A triage nurse has four clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first?

• A. A 2-month-old infant with a history of rolling off the bed and having a bulging fontanelle with crying
• B. A teenager who suffered singed facial hair while camping
• C. An elderly client with complaints of frequent liquid brown-colored stools
• D. A middle-aged client with intermittent pain behind the right scapula

Correct answer: B

Rationale: The correct answer is the teenager who suffered singed facial hair while camping. This client is in the greatest danger with a potential risk of respiratory distress. Singed facial hair indicates exposure to heat or fire in close range, which could have caused serious damage to the interior of the lungs. It's crucial to prioritize this client as the interior lining of the lungs has no nerve fibers, so swelling may not be immediately noticeable. The other choices, while concerning, do not present an immediate life-threatening situation. The infant's condition may be serious but does not pose an immediate danger of respiratory distress. The elderly client's symptoms could indicate gastrointestinal issues, which are important but not as urgent as potential respiratory compromise. The middle-aged client's pain behind the right scapula, while uncomfortable, does not indicate an acute life-threatening condition requiring immediate attention.

3. Which of the following interventions is most appropriate for a client with a diagnosis of Risk for Activity Intolerance?

• A. Perform nursing activities throughout the entire shift
• B. Assess for signs of increased muscle tone
• C. Minimize environmental noise
• D. Teach clients to perform the Valsalva maneuver

Correct answer: C

Rationale: The most appropriate intervention for a client diagnosed with Risk for Activity Intolerance is to minimize environmental noise. Environmental noise can increase the energy demand on the client as they try to manage their responses to stimuli. By reducing excess noise, the nurse helps promote rest and conserves the client's energy, which is crucial in managing activity intolerance. Choice A is incorrect because increasing nursing activities may exacerbate the client's intolerance to activity. Choice B is incorrect as assessing for signs of increased muscle tone does not directly address the issue of activity intolerance. Choice D is incorrect as teaching the Valsalva maneuver is not relevant to managing activity intolerance in this scenario.

4. Your patient who had AIDS/HIV has just died. Should you still use standard precautions as you provide post-mortem care?

• A. Yes, because the virus is still transmissible
• B. Yes, because respect must still be maintained
• C. No, because the virus is no longer transmissible
• D. No, because it is disrespectful

Correct answer: A

Rationale: Yes, you should still use standard precautions even after an HIV/AIDS patient has died. The virus can remain infectious after death, and healthcare workers need to protect themselves from potential exposure. Choice B is incorrect because while respect is important, the primary reason for using standard precautions is to prevent transmission of infectious diseases. Choice C is incorrect as the virus can still be transmissible even after the patient's death. Choice D is incorrect as using standard precautions is a matter of infection control, not a question of respect.

5. What does an individual who believes in the magicoreligious theory of illness and disease think is the cause of illness?

• A. Germs and viruses
• B. Supernatural forces
• C. Eating imbalanced (hot/cold) foods
• D. Imbalance within his or her spiritual nature

Correct answer: B

Rationale: Individuals who adhere to the magicoreligious theory of illness and disease attribute the cause of illness to supernatural forces. In this perspective, the world is perceived as governed by supernatural forces that influence the well-being of individuals. The belief is that these forces can bring about both good and evil outcomes. Choices A, C, and D are incorrect. Germs and viruses are associated with the biomedical theory of illness. Eating imbalanced hot or cold foods is linked to the yin/yang naturalist theory. Imbalance within one's spiritual nature is not a recognized cause of illness in any of the established theories of illness.

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