Nursing Elites

1. The nurse determines that a client's body weight is 105% above the standardized height-weight scale. Which related factor should the nurse include in the nursing problem, 'Imbalanced nutrition: More than body requirements'?

• A. Hypertension.
• B. Diabetes mellitus.
• C. Inadequate lifestyle changes in diet and exercise.
• D. Increased risk of chronic illnesses.

Correct answer: C

Rationale: The correct answer is C: 'Inadequate lifestyle changes in diet and exercise.' When a client's weight exceeds the standardized height-weight scale significantly, it indicates an imbalance between nutrition intake and energy expenditure, leading to 'Imbalanced nutrition: More than body requirements.' Inadequate lifestyle changes in diet and exercise directly contribute to this imbalance by promoting excessive caloric intake and reduced physical activity. Choices A, B, and D are incorrect because while conditions like hypertension, diabetes mellitus, and increased risk of chronic illnesses may be consequences of imbalanced nutrition, they are not the direct related factor that should be included in formulating the nursing problem.

2. The nurse is preparing a presentation on sexually transmitted infections (STIs) for a group of high school students. Which strategy is most effective for this age group?

• A. providing detailed statistical data on STI rates
• B. distributing brochures about STI prevention
• C. showing a documentary on the impact of STIs
• D. facilitating a discussion on safe sex practices

Correct answer: D

Rationale: Facilitating a discussion on safe sex practices is the most effective strategy for high school students when educating about sexually transmitted infections (STIs). This approach encourages active participation, allows students to ask questions, share experiences, and engage with the topic in a meaningful way. Providing detailed statistical data may overwhelm the students and not resonate with them effectively. Distributing brochures can be informative but might not promote the same level of interaction and understanding as a discussion. Showing a documentary is a passive method that may not engage the students actively or address their specific questions and concerns.

3. After assessing the health care needs of an elementary school, the nurse determines that an increased prevalence of pediculosis capitis is a priority problem. The nurse develops a 2-month program with the goal to eradicate the condition in the school. The program includes educational pamphlets sent home to parents and regular assessment of children by the school nurse. What action should the nurse implement to evaluate the effectiveness of the program?

• A. evaluate the teachers' ability to identify pediculosis capitis 2 months after initiation of the program
• B. conduct an initial examination of each child in the school to obtain baseline data
• C. survey parents 3 weeks after pamphlets are sent home to assess their understanding of the condition
• D. measure the prevalence of pediculosis capitis among the children after four months

Correct answer: D

Rationale: Measuring the prevalence of pediculosis capitis among the children after four months is the most appropriate action to evaluate the program's effectiveness. This approach provides data on the program's long-term impact and effectiveness in eradicating the condition. Option A focuses on the teachers' ability, which is not directly related to the program's effectiveness in eradicating the condition. Option B suggests conducting an initial examination, which does not provide information on the program's impact. Option C involves assessing parents' understanding, which is important but does not directly evaluate the program's effectiveness in eradicating pediculosis capitis.

4. During a 2-week postoperative follow-up home visit, a female client who had gastric bypass surgery exhibits abdominal tenderness, shoulder pain, and describes feelings of malaise. Her vital signs are: T 101.8, BP 100/50, HR 104, and RR 18. Which action should the RN take?

• A. have the client transported via ambulance to the hospital
• B. recheck the client's vital signs in 30 minutes
• C. instruct the client to drive to the hospital for admission
• D. assess the client's current symptoms

Correct answer: A

Rationale: The client is presenting with signs of a potential postoperative complication, such as fever, low blood pressure, and tachycardia, which could indicate sepsis or another serious issue. These symptoms require immediate hospital evaluation and management. Option B of rechecking vital signs in 30 minutes could delay crucial intervention in a potentially life-threatening situation. Option C is unsafe as the client should not drive herself due to her condition. Option D is vague and does not address the urgency of the situation.

5. The nurse is assisting with the triage of clients at a large community disaster and finds a man lying on the ground, who states that the blast threw him out of a second-story window. Which action should the nurse implement first?

• A. Logroll the client to his side and assess for back injuries
• B. Perform a complete neurological assessment
• C. Open the client's airway immediately
• D. Place the nurse's hands around the client's neck to stabilize

Correct answer: C

Rationale: Opening the client's airway immediately is the priority in this scenario. Ensuring the airway is clear takes precedence over other actions as it is crucial for the client's breathing and oxygenation. Logrolling the client to assess for back injuries may worsen the condition if there are spinal injuries, so this should not be done as the first step. Performing a complete neurological assessment is important but not the immediate priority over ensuring the airway is clear. Placing the nurse's hands around the client's neck to stabilize is incorrect and could potentially harm the client, as neck stabilization should only be done if there is a suspected neck injury, which is not indicated in this case.

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