Nursing Elites

1. Mrs. Peterson complains of difficulty falling asleep, awakening earlier than desired, and not feeling rested. She attributes these problems to leg pain that is secondary to her arthritis. What is the most appropriate nursing diagnosis for her?

• A. Sleep Pattern Disturbances (related to chronic leg pain)
• B. Fatigue (related to leg pain)
• C. Knowledge Deficit (regarding sleep hygiene measures)
• D. Sleep Pattern Disturbances (related to chronic leg pain)

Correct answer: D

Rationale: The most appropriate nursing diagnosis for Mrs. Peterson is 'Sleep Pattern Disturbances (related to chronic leg pain).' Mrs. Peterson's sleep issues are directly linked to her chronic leg pain, which is a result of her arthritis. This nursing diagnosis addresses the primary cause of her sleep disturbances and allows for interventions that focus on managing the pain to improve her sleep. Choices A, B, and C are incorrect. Choice A correctly identifies the relationship between sleep disturbances and chronic leg pain, addressing the root cause. Choice B is incorrect as it only focuses on fatigue and does not encompass the broader sleep issues. Choice C is not relevant as there is no indication that Mrs. Peterson lacks knowledge about sleep hygiene measures.

2. When a client needs oxygen therapy, what is the highest flow rate that oxygen can be delivered via nasal cannula?

• A. 2 liters/minute
• B. 4 liters/minute
• C. 6 liters/minute
• D. 8 liters/minute

Correct answer: C

Rationale: The correct answer is 6 liters/minute. When a client requires oxygen therapy, the maximum flow rate that oxygen can be delivered via nasal cannula is 6 liters/minute. Nasal cannula can effectively deliver oxygen up to 6 liters/minute. Flow rates exceeding 6 liters/minute may lead to drying of the nasal passages and discomfort for the client. Higher flow rates, like 8 liters/minute, should be administered using a mask to ensure sufficient oxygenation. Options A, B, and D are incorrect as they indicate flow rates that surpass the recommended maximum for nasal cannula delivery.

3. While taking care of a client, the nurse thinks that physical therapy in the hospital might be beneficial to their condition. The following is the ideal referral process EXCEPT?

• A. Transport the client to the physical therapy room for treatment after receiving an official referral.
• B. Provide the physical therapist with the client's medical record after the referral.
• C. Contact the client's primary care provider to suggest a physical therapy referral.
• D. Request the client to self-refer to the physical therapist.

Correct answer: D

Rationale: The ideal referral process for a client to receive physical therapy in the hospital starts with the nurse contacting the client's primary care provider to discuss and suggest a physical therapy referral. The primary care provider should provide an official referral, which is crucial for initiating the treatment process. After obtaining the official referral, the nurse should provide the physical therapist with the client's medical record. This step is essential for the therapist to assess the client's condition and customize the treatment plan accordingly. Once the physical therapist is informed and prepared, the nurse can then transport the client to the physical therapy room for treatment. Therefore, the correct sequence is to first contact the primary care provider (Choice C), then provide the medical record (Choice B), and finally transport the client for treatment (Choice A). Choice D, suggesting the client self-refer to the physical therapist, is incorrect as the referral process should involve healthcare professionals to ensure proper assessment and treatment planning.

4. A client turns her ankle. She is diagnosed as having a Pulled Ligament. This should be documented as a:

• A. sprain.
• B. strain.
• C. subluxation.
• D. dislocation.

Correct answer: B

Rationale: A sprain is the correct term for the excessive stretching of a ligament, which is what happens when a ligament is pulled. A strain involves muscle tissue. Subluxation refers to a partial dislocation, and dislocation is a complete displacement of bones in a joint. In this case, since it's a pulled ligament, the most appropriate term is a sprain.

5. Which of the following nursing diagnoses is most appropriate for a client with a new colostomy?

• A. Excess Fluid Volume
• B. Risk for Aspiration
• C. Disturbed Body Image
• D. Urinary Retention

Correct answer: C

Rationale: Disturbed Body Image is the most appropriate nursing diagnosis for a client with a new colostomy. A new colostomy can significantly impact a person's body image and self-esteem due to the physical changes it brings. This can lead to emotional distress, adjustment issues, and concerns about body image. Excess Fluid Volume, Risk for Aspiration, and Urinary Retention are not directly related to the psychosocial impact of a new colostomy and are therefore not as relevant in this context. While Excess Fluid Volume, Risk for Aspiration, and Urinary Retention are important nursing diagnoses, they are not the priority when considering the psychological and emotional effects of a new colostomy.

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