Nursing Elites

1. The medical record for a client states that the client has hemiplegia. What does this mean?

• A. The client can use his right arm, left leg, and left arm.
• B. The client has paralysis of all four extremities.
• C. The client has decreased vision in one eye.
• D. The client has paralysis on one side of the body.

Correct answer: D

Rationale: Hemiplegia refers to paralysis on one side of the body, affecting either the right or left side. Choice A is incorrect because it describes selective paralysis of specific limbs, not one side of the body. Choice B is incorrect as hemiplegia does not involve paralysis of all four extremities. Choice C is also incorrect as decreased vision in one eye is not indicative of hemiplegia.

2. The client with rheumatoid arthritis is having her rheumatoid factor (RF) drawn while she is having a flare-up of the disease. Which result is seen in clients with rheumatoid arthritis?

• A. Factor does not change
• B. Decreased level of rheumatoid arthritis
• C. A positive rheumatoid factor
• D. A negative rheumatoid factor

Correct answer: C

Rationale:

3. 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.

4. A nurse is teaching a client who has out about dietary recommendations. The nurse should teach the client which of the following beverages can trigger an attack?

• A. Fruit juice
• B. Alcohol
• C. Milk
• D. Coffee

Correct answer: B

Rationale:

5. What finding is often present in a client with osteoporosis?

• A. Chronic pain
• B. Dupuytren’s contracture
• C. Inflammation
• D. Kyphosis

Correct answer: D

Rationale: Kyphosis is a common finding in osteoporosis due to vertebral compression fractures. Chronic pain (Choice A) can occur in osteoporosis but is not a specific finding. Dupuytren’s contracture (Choice B) is a condition affecting hand fingers' connective tissue, not typically associated with osteoporosis. Inflammation (Choice C) is not a typical finding in osteoporosis but rather a characteristic of other conditions.

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