Nursing Elites

1. When assisting a family who fails to take action during a sick member despite suggestions, you will:

• A. explain the consequences of inaction
• B. identify the courses of action open to the family and the resources needed for each
• C. discuss the consequences of each course of action available
• D. influence the family to act on what you think is best for the situation

Correct answer: B

Rationale: When helping a family decide on actions to take, it is essential to identify the courses of action available to them and the resources needed for each. This empowers the family to make informed decisions based on their specific situation. Explaining the consequences of inaction (Choice A) may be necessary but does not provide a range of options. Discussing the consequences of each course of action (Choice C) is important but does not actively guide the family on the available actions. Influencing the family (Choice D) to act based on personal judgment undermines their autonomy and may not lead to the best outcome.

2. The home health care agency can expect to obtain Medicare reimbursement for which home visit performed by a registered nurse (RN) or a practical nurse (PN)?

• A. Assessment of the speech pattern of a mobile adult who had a mild stroke last year.
• B. Safety teaching for an older male client whose wife complains that he uses an unsafe ladder while painting.
• C. Wound care for a client who had a postoperative infection following abdominal surgery two weeks ago.
• D. Evaluation of crutch use by a 65-year-old male client who broke his tibia while snow skiing.

Correct answer: C

Rationale: The correct answer is C because wound care for a postoperative infection is a skilled service that qualifies for Medicare reimbursement. Choices A, B, and D involve assessments, teaching, and evaluation, which may not meet the criteria for Medicare reimbursement as they do not directly involve a skilled nursing service related to a postoperative condition.

3. The nurse is evaluating the growth and development of a toddler with AIDS. The nurse would anticipate finding that the child has

• A. Achieved developmental milestones at an erratic rate
• B. Delay in musculoskeletal development
• C. Displayed difficulty with speech development
• D. Delay in achievement of most developmental milestones

Correct answer: D

Rationale: Children with AIDS often experience delays in achieving developmental milestones, affecting their overall growth and development. This delay can impact various areas of development, not limited to a specific aspect like musculoskeletal or speech development. While some children may achieve milestones at varying rates (choice A), the general trend is a delay in multiple milestones (choice D). Musculoskeletal development (choice B) and speech development (choice C) may be affected but are not as comprehensive as the delay in most developmental milestones.

4. A hospitalized child suddenly has a seizure while his family is visiting. The nurse notes whole body rigidity followed by general jerking movements. The child vomits immediately after the seizure. A priority nursing diagnosis for the child is

• A. High risk for infection related to vomiting
• B. Altered family processes related to chronic illness
• C. Fluid volume deficit related to vomiting
• D. Risk for aspiration related to loss of consciousness

Correct answer: D

Rationale: Risk for aspiration is a priority concern following a seizure, especially when the child vomits, as there is a danger of aspirating the vomit into the lungs, leading to respiratory complications. The other options are not the priority in this situation. While infection risk and fluid volume deficit are important, ensuring the child's airway is clear and there is no risk of aspiration takes precedence. Altered family processes may be a concern but addressing the immediate physiological risk is the priority.

5. A client with asthma has low-pitched wheezes present on the final half of exhalation. One hour later the client has high-pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client

• A. Has increased airway obstruction
• B. Has improved airway obstruction
• C. Needs to be suctioned
• D. Exhibits hyperventilation

Correct answer: A

Rationale: The correct answer is A: 'Has increased airway obstruction.' High-pitched wheezes extending throughout exhalation indicate a worsening airway obstruction, leading to increased resistance in the airways. Low-pitched wheezes present on the final half of exhalation may suggest some level of obstruction, but the change to high-pitched wheezes throughout exhalation indicates a progression in the obstruction. Choice B is incorrect as the change in wheeze characteristics signifies deterioration rather than improvement. Choice C is incorrect as suctioning is not indicated based on the wheeze assessment findings. Choice D is incorrect as hyperventilation does not typically present with wheezes and is not supported by the information provided.

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