Nursing Elites

1. On inspection, which client does the nurse suspect of having a visual impairment?

• A. The client whose sclera is white
• B. The client who has an intact blink reflex
• C. The client who is tilting their head
• D. The client with equal pupils

Correct answer: C

Rationale: Tilting the head may indicate a visual impairment as the client attempts to compensate for vision loss.

2. A nurse is teaching a client how to follow a low-purine diet as prescribed by the provider for the management of gout. What statement by the client indicates a correct understanding of the teaching?

• A. "I should choose red meat instead of poultry."?
• B. "I should avoid eating liver and other organ meats."?
• C. I can drink only white wine."?
• D. "I will need to limit the number of fruit servings each day."?

Correct answer: B

Rationale:

3. A client with acquired immunodeficiency syndrome (AIDS) has pneumocystis carinii (PCP). What is the nurse's priority assessment for this client?

• A. Skin turgor
• B. Lung sounds
• C. Radial pulses
• D. Capillary refill

Correct answer: B

Rationale:

4. What is the priority nursing diagnosis for a client with immobility?

• A. Constipation related to immobility
• B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
• C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
• D. Risk for disuse syndrome as evidenced by immobility

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.

5. Antibodies are passed from mother to fetus through the placenta. What is this type of immunity called?

• A. Artificial passive
• B. Natural passive
• C. Natural active
• D. Artificial active

Correct answer: B

Rationale:

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