Nursing Elites

1. The client states, “the doctor says I am nearsighted. I do not get it.” What would be the best response by the nurse?

• A. I am sorry you did not understand. Would you like a different doctor?
• B. Nearsighted, or myopia means that you have difficulty seeing things at a distance.
• C. You will need to have glasses.
• D. This means you won’t ever need glasses.

Correct answer: B

Rationale: The correct response is to explain to the client what nearsightedness means, which is having difficulty seeing distant objects, as known as myopia. Choice A is not helpful as changing doctors is not necessary for this situation. Choice C is premature as wearing glasses is a possible solution but not the only one. Choice D is incorrect as nearsightedness (myopia) often requires glasses for correction.

2. The nurse is caring for a 65-year-old client and notes a temperature of 101�F. How does the nurse interpret this finding?

• A. Hyperthermia
• B. A cold environment
• C. Normal
• D. Hypothermia

Correct answer: A

Rationale: A temperature of 101�F is indicative of hyperthermia, which is an elevated body temperature. Hyperthermia is commonly associated with fever or environmental factors such as excessive heat exposure. Choice B, 'A cold environment,' is incorrect as hyperthermia refers to elevated body temperature, not a cold environment. Choice C, 'Normal,' is incorrect as a temperature of 101�F is above the normal range for body temperature. Choice D, 'Hypothermia,' is incorrect as hypothermia refers to a low body temperature, not an elevated one.

3. What is an example of a client's primary defense to infection?

• A. Intact skin
• B. Inflammation
• C. Phagocytosis
• D. Fever

Correct answer: A

Rationale:

4. The client states, "Why am I getting protein supplements while I am healing from a bed sore?"? What is the best response by the nurse?

• A. Because it is easy to digest.'
• B. Protein has amin acid that promotes wound healing.'
• C. If you do not like it, you do not have to take it.'
• D. These supplements have nothing to do with your wound,'

Correct answer: B

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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