Nursing Elites

1. The client asks the nurse what nonpharmacological intervention can be used to reduce pain and swelling in her joints affected by rheumatoid arthritis. What is the most appropriate response by the nurse?

• A. "Ice packs can be used to reduce swelling but should be removed after 20 minutes."?
• B. "Heat always makes the swelling go down. You do not need any other interventions."?
• C. "Try high impact exercise exercise like running to loosen up your joints and reduce pain."?
• D. "Apply ice packs. It is generally okay to keep them on for up to one hour at a time."?

Correct answer: A

Rationale:

2. A nurse is teaching a client who has fibromyalgia about strategies that might help reduce her symptoms. What should the nurse include in the client education?

• A. Avoid exercise during flare-ups
• B. Do high impact exercises like running
• C. Establish a regular sleep pattern
• D. Increase calcium and caffeine intake

Correct answer: C

Rationale:

3. The following client come to the ophthalmology clinic. Which client needs to be seen first?

• A. Client who had recent cataract surgery and has worsening vision
• B. Client with an absent red reflex on ophthalmic examination
• C. Client with an intraocular pressure of 24 mm Hg
• D. Client with a tearing, reddened eye with exudate

Correct answer: A

Rationale: Worsening vision after cataract surgery requires immediate attention to prevent complications.

4. A client is in the emergency room in critical condition and hypotensive. Her spouse is distraught. What is the priority nursing action?

• A. Maintain the client's blood pressure
• B. Call a chaplain
• C. Provide the spouse a chair
• D. Ask the client's spouse to explain what happened

Correct answer: A

Rationale:

5. 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.

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