Nursing Elites

1. The nurse assesses a client for physiological risk factors for falls. The nurse should conclude that the client is not at risk if which of the following is discovered?

• A. history of dizziness
• B. need for a wheelchair due to reduced mobility
• C. weakness and fatigue noted when climbing stairs
• D. intact recent and remote memory

Correct answer: D

Rationale: The correct answer is intact recent and remote memory. Intact memory function indicates that the client is less likely to be at risk for falls as it suggests cognitive awareness and orientation, which are important for safety. Choices A, B, and C are risk factors for falls: a history of dizziness can lead to imbalance, the need for a wheelchair due to reduced mobility can increase fall risk, and weakness and fatigue when climbing stairs indicate physical limitations that predispose a client to falls. Therefore, these options would suggest an increased risk for falls.

2. Which of the following might be an appropriate nursing diagnosis for an epileptic client?

• A. Dysreflexia
• B. Risk for Injury
• C. Urinary Retention
• D. Unbalanced Nutrition

Correct answer: B

Rationale: The correct answer is 'Risk for Injury.' Epileptic clients are at risk for injury due to complications of seizure activity, such as falls that could lead to head trauma. 'Dysreflexia' is not typically associated with epilepsy but rather with spinal cord injury. 'Urinary Retention' is not a common nursing diagnosis for epileptic clients unless specifically indicated. 'Unbalanced Nutrition' may not be a priority nursing diagnosis compared to the immediate risk of injury in epileptic clients.

3. The nurse manager of a quality improvement program asks a nurse in the neurological unit to conduct a retrospective audit. Which action should the auditing nurse plan to perform in this type of audit?

• A. Checking the crash cart to ensure that all needed supplies are readily available in case of an emergency
• B. Checking the documentation written by a new nursing graduate on her assigned clients at the end of the shift
• C. Reviewing neurological assessment checklists for all clients on the unit to ensure that these assessments are being conducted as prescribed
• D. Obtaining the assigned medical record from the hospital's medical record room to review documentation made during a client's hospital stay

Correct answer: D

Rationale: Quality improvement, also known as performance improvement, focuses on processes contributing to client safety and care outcomes. Retrospective audits involve reviewing medical records after discharge for compliance with standards. Concurrent audits assess staff compliance during a client's stay. Therefore, obtaining the medical record from the hospital's record room for review is crucial in a retrospective audit. Options A, B, and C are more suited for concurrent audits as they involve real-time assessment during a client's stay.

4. What information does the healthcare provider remember regarding do-not-resuscitate (DNR) orders in this scenario?

• A. That a DNR order may be written by a healthcare provider
• B. That everything possible must be done if the client stops breathing
• C. That medications only may be given to the client if the client stops breathing
• D. That life support measures will have to be implemented if the client stops breathing

Correct answer: A

Rationale: In a situation where a client has no family members and the client's wife is mentally incompetent, the healthcare provider may write a DNR order if it is deemed medically certain that resuscitation would be futile. A DNR order is a medical directive that instructs healthcare providers not to perform CPR if a patient's heart stops or if the patient stops breathing. Option A is correct because a DNR order can indeed be issued by a healthcare provider under certain circumstances, as it is a medical decision. Options B, C, and D are incorrect as they do not accurately reflect the concept of DNR orders and the decision-making process involved in such situations.

5. A client with dysphagia is ready to eat lunch. Which of these foods on the tray would be best to start with when assisting the client?

• A. diced fruit
• B. apple juice with a liquid thickener
• C. Jell-O�
• D. toast

Correct answer: B

Rationale: The correct choice is apple juice with a liquid thickener. A client with dysphagia is at risk for aspiration, so it is crucial to start with liquids and assess the client's ability to swallow before introducing solid foods. Using a liquid thickener with apple juice allows the healthcare provider to evaluate swallowing function. Jell-O�, although it melts into a clear liquid, should be avoided initially as it may not provide a clear assessment of swallowing ability. Diced fruit and toast are solid foods that should be introduced only after the client's swallowing ability with liquids has been assessed.

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