Nursing Elites

1. When assessing Mr. Lee's eye condition, what general information should the nurse seek?

• A. Type of employment.
• B. Burning or itchy sensation in the eyes.
• C. Position of the eyelids.
• D. Existence of floaters.

Correct answer: A

Rationale: When assessing a patient's eye condition, the nurse should seek general information such as the type of employment, activities, allergies, medications, lenses, and protective devices used. This information helps in understanding potential exposures to irritants and risks related to activities. While the presence of burning or itchy sensation in the eyes, position of the eyelids, and existence of floaters are important aspects to assess during a focused eye examination, during the initial assessment, the type of employment is more relevant for understanding possible environmental factors affecting eye health.

2. A healthcare professional is assisting with data collection of a client with suspected cholecystitis. Which finding does the healthcare professional expect to note if cholecystitis is present?

• A. Homan sign
• B. Murphy sign
• C. Blumberg sign
• D. McBurney sign

Correct answer: B

Rationale: The correct answer is B: Murphy sign. The Murphy sign is an indicator of gallbladder disease. It involves the examiner placing fingers under the liver border while the client inhales. If the gallbladder is inflamed, it descends onto the fingers, causing pain. The Homan sign is associated with pain in the calf area upon sharp dorsiflexion of the foot, indicating deep vein thrombosis. The Blumberg sign is the presence of rebound tenderness on palpation of the abdomen, indicating peritoneal irritation. The McBurney sign is indicative of appendicitis, presenting as severe pain and tenderness upon palpation at McBurney's point in the right lower quadrant of the abdomen.

3. The LPN is caring for a client newly diagnosed with HIV. Which statement made by the client regarding antiretroviral therapy (ART) would require correction from the nurse?

• A. "If I start ART and use condoms, I'm less likely to transmit HIV to my partner."?
• B. "I can still use ART even though I am Hepatitis C positive."?
• C. "I will need to be on ART indefinitely."?
• D. "I know I will need to come back for blood draws so that I can begin ART when my CD4 count is over 1,000 cells/mm3."?

Correct answer: D

Rationale: The correct answer is the statement, "I know I will need to come back for blood draws so that I can begin ART when my CD4 count is over 1,000 cells/mm3."? This statement would require correction from the nurse because initiating ART when the CD4 count is over 1,000 cells/mm3 is not supported by guidelines. The World Health Organization (WHO) recommends making treatment a priority for those with a CD4 count of ?350 cells/mm3, as early intervention can help delay disease progression. Therefore, waiting for a CD4 count of over 1,000 cells/mm3 is not in line with current recommendations. Choice A is correct, as studies have shown that using condoms along with ART can significantly reduce the risk of HIV transmission to sexual partners. Choice B is also correct because being Hepatitis C positive does not contraindicate the use of ART. Choice C is correct as well, as ART is typically needed indefinitely to maintain viral suppression and manage HIV. Therefore, the only statement that would require correction is Choice D.

4. A client who is experiencing infertility says to the nurse, 'I feel I will be incomplete as a man/woman if I cannot have a child.' Which of the following nursing diagnoses is likely to be appropriate for this client?

• A. Risk for Self-Harm
• B. Body Image Disturbance
• C. Ineffective Role Performance
• D. Powerlessness

Correct answer: B

Rationale: The correct nursing diagnosis for this client is 'Body Image Disturbance.' The client's statement reflects concerns about self-identity and feeling incomplete due to infertility, which aligns with Body Image Disturbance. The statement does not directly indicate a risk for self-harm, so 'Risk for Self-Harm' is not the correct choice. 'Ineffective Role Performance' is not the best option as it does not address the client's primary concern regarding self-image. While 'Powerlessness' could be appropriate if the client expressed feelings of powerlessness related to infertility, it is not the most suitable diagnosis based on the given statement.

5. A nurse is conducting a psychosocial assessment of a young adult. Which observations would lead the nurse to determine that the client is demonstrating a sign of emotional health?

• A. The young adult is sensitive to criticism.
• B. The young adult verbalizes unrealistic fears.
• C. The young adult verbalizes disappointment with life.
• D. The young adult verbalizes satisfaction with friendships.

Correct answer: D

Rationale: The correct answer is that the young adult verbalizes satisfaction with friendships. Emotional health in young adults is characterized by various positive signs, including satisfaction with social interactions and friendships. Expressing contentment with friendships indicates a healthy emotional state, fostering positive social connections. On the other hand, sensitivity to criticism, verbalizing unrealistic fears, and expressing disappointment with life are all indicative of emotional distress and potential mental health challenges. These behaviors can hinder social relationships and overall emotional well-being.

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