Nursing Elites

1. How can the nurse promote relief of muscle pain, spasms, and tension?

• A. Encouraging the client to continue their activities as usual.
• B. Immobilizing the client.
• C. Applying heat, cold, pressure, or vibration to the painful area.
• D. Administering pain medication as needed to ease the muscle.

Correct answer: C

Rationale: To promote relief of muscle pain, spasms, and tension, the nurse should consider applying heat, cold, pressure, or vibration to the painful area. These interventions can help alleviate pain associated with muscle tension, pain, or spasms. Choice A is incorrect because encouraging the client to continue their activities as usual may exacerbate the pain. Choice B is incorrect as immobilizing the client may not address the underlying issue and could potentially lead to further complications. Choice D is also incorrect because while pain medication can be used, it is not the first-line treatment for muscle pain, spasms, and tension.

2. The nurse is teaching a community health class for cancer prevention and screening. Which individual has the highest risk for colon cancer?

• A. Client with irritable bowel syndrome
• B. Family history of colon polyps
• C. Client with cirrhosis of the liver
• D. History of colon surgery

Correct answer: B

Rationale: A family history of colon polyps and/or colon cancer is a significant risk factor for developing colon cancer. Individuals with a family history are more likely to develop colon cancer due to genetic predisposition. While other factors like irritable bowel syndrome, cirrhosis of the liver, and history of colon surgery may contribute to an increased risk of colon cancer, having a family history of colon polyps is the highest risk factor. Irritable bowel syndrome does not directly increase the risk of colon cancer. Cirrhosis of the liver is associated with liver cancer rather than colon cancer. A history of colon surgery may reduce the risk of colon cancer in some cases by removing precancerous polyps.

3. Chemotherapeutic agents often produce a degree of myelosuppression including leukopenia. Leukopenia does not present immediately but is delayed several days or weeks because:

• A. the client's hemoglobin and hematocrit are normal.
• B. red blood cells are affected first.
• C. folic acid levels are normal.
• D. the current white cell count is not affected by chemotherapy.

Correct answer: D

Rationale: Leukopenia does not present immediately after chemotherapy because time is required to clear circulating cells before the effect on precursor cell maturation in the bone marrow becomes evident. Leukopenia is characterized by an abnormally low white blood cell count. The correct answer is D because the white cell count is not immediately affected by chemotherapy. Choices A, B, and C are incorrect as they pertain to red blood cells (hemoglobin and hematocrit), which are not directly related to the delayed onset of leukopenia.

4. Which type of exercises might be prescribed to strengthen the pelvic floor muscles of a client with urinary incontinence?

• A. Kegel
• B. resistance
• C. passive
• D. stretching

Correct answer: A

Rationale: The correct answer is Kegel. Kegel exercises are specifically designed to strengthen the pelvic floor muscles, making them an effective treatment for urinary incontinence. These exercises involve contracting and relaxing the pelvic floor muscles, which helps to improve muscle tone and control. Choice B, resistance exercises, may not directly target the pelvic floor muscles as effectively as Kegel exercises. Passive exercises (Choice C) do not actively engage the muscles and are unlikely to strengthen the pelvic floor. Stretching exercises (Choice D) focus on increasing flexibility rather than muscle strength, so they are not the most appropriate for strengthening the pelvic floor muscles in the context of urinary incontinence.

5. Which of the following situations requires nurse intervention?

• A. A certified nursing assistant states, 'The patient in 307 is not wearing gloves while shaving her legs.'
• B. A nursing assistant at the nursing station states, 'The patient in 307 has a respiratory rate of 16.'
• C. A nursing student in the cafeteria states, 'Dr. Jones told the patient in room 307 that she was going to die.'
• D. A certified nursing assistant states, 'Dr. Jones hasn't made rounds this morning.'

Correct answer: C

Rationale: The correct answer is C. Patient confidentiality must be maintained at all times to respect the patient's privacy and dignity. Disclosing sensitive information like a patient's prognosis in a public setting violates confidentiality and can cause distress. The nurse should intervene in this situation and educate the nursing student about the importance of not discussing confidential patient information in public. Choices A, B, and D do not involve breaching patient confidentiality and do not require immediate nurse intervention. Choice A focuses on infection control measures, choice B relates to clinical assessment, and choice D is about the doctor's rounds, which are not urgent matters requiring immediate intervention.

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