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. A client is receiving atenolol (Tenormin) 25 mg PO after a myocardial infarction. The nurse determines the client's apical pulse is 65 beats per minute. What action should the nurse take next?

• A. Hold the medication.
• B. Call the healthcare provider.
• C. Administer the medication.
• D. Check the blood pressure.

Correct answer: C

Rationale: The correct action for the nurse to take next is to administer the medication. Atenolol is a beta-blocker commonly used post-myocardial infarction to reduce the workload of the heart. The client's apical pulse of 65 beats per minute is within the acceptable range after a myocardial infarction. Holding the medication or calling the healthcare provider is not necessary in this scenario as the pulse rate is appropriate for administering atenolol. Checking the blood pressure is not the priority in this situation, as the focus should be on the heart rate when administering atenolol.

3. The healthcare provider is preparing to administer digoxin (Lanoxin) to a client. Which assessment finding should the healthcare provider report before administering the medication?

• A. Apical pulse of 58 beats per minute.
• B. Serum potassium level of 3.0 mEq/L.
• C. Blood pressure of 140/90 mm Hg.
• D. Client reports seeing halos around lights.

Correct answer: D

Rationale: Seeing halos around lights is a classic symptom of digoxin toxicity, known as visual disturbances. This finding indicates an adverse effect of digoxin and should be reported immediately to the healthcare provider. Monitoring for visual changes is crucial as it can progress to more severe toxicity, leading to life-threatening dysrhythmias or other complications. Apical pulse, serum potassium level, and blood pressure are important assessments when administering digoxin, but the presence of visual disturbances, such as seeing halos around lights, takes precedence due to its direct association with digoxin toxicity. Changes in these other parameters should also be noted and addressed, but they are not the priority when compared to a symptom directly linked to potential toxicity.

4. The public health nurse is called to investigate a report of several cases of chickenpox at a daycare center. The daycare worker states that five children have been sent home over the past two weeks with fever and itchy blisters. Which intervention should the nurse implement first?

• A. Validate that the children sent home did develop chickenpox
• B. Report the presence of a viral endemic at the daycare center
• C. Confirm the number of children with symptoms
• D. Determine how many people have been exposed

Correct answer: A

Rationale: Validating that the children sent home did develop chickenpox is the most crucial initial step for the nurse. This intervention ensures that the appropriate public health measures are implemented for the containment of chickenpox. Reporting a viral endemic or confirming the number of children with symptoms may be important but are secondary to confirming the diagnosis. Determining the number of people exposed comes after confirming the diagnosis to assess the extent of the outbreak and implement necessary control measures.

5. A public health nurse is working with a community to improve vaccination rates. Which intervention is most likely to be effective?

• A. Setting up vaccination clinics in accessible locations
• B. Distributing flyers with information about vaccines
• C. Offering incentives for getting vaccinated
• D. Partnering with local businesses to promote vaccination

Correct answer: A

Rationale: Setting up vaccination clinics in accessible locations is the most effective intervention to improve vaccination rates. This intervention ensures easy access to vaccination services for community members, removing barriers such as transportation or time constraints. Distributing flyers (Choice B) may increase awareness but may not directly address access issues. Offering incentives (Choice C) might temporarily boost vaccination rates but may not lead to sustained behavior change. Partnering with local businesses (Choice D) could be beneficial for promotion but may not directly impact vaccination accessibility.

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