Nursing Elites

1. The healthcare provider is assessing a client who has returned from surgery. Which finding requires immediate intervention?

• A. Heart rate of 90 beats per minute.
• B. Oxygen saturation of 92%.
• C. Temperature of 99°F (37.2°C).
• D. Pain at the surgical site.

Correct answer: C

Rationale: A temperature of 99°F (37.2°C) in a postoperative client requires immediate intervention as it may indicate the presence of infection. Elevated temperature post-surgery can be a sign of surgical site infection or systemic infection, which can lead to serious complications if not addressed promptly. Monitoring and managing a fever in a postoperative client is crucial to prevent further complications. The other findings, such as a heart rate of 90 beats per minute, oxygen saturation of 92%, and pain at the surgical site, are common postoperative assessments that may not necessarily require immediate intervention unless they are significantly out of normal range or causing severe distress to the client.

2. A female adult walks into a local community health clinic and tells the nurse that she is homeless and cannot seem to find help. Which statement indicates to the nurse that a client is feeling separated from society and helpless?

• A. "I'm feeling really isolated from everyone and scared."
• B. "I feel like I cannot get enough food to live any longer."
• C. "I know that I will always be poor so what's the use of trying?"
• D. "People like me are never respected, no matter how well we do."

Correct answer: A

Rationale: Choice A is the correct answer because the statement reflects a sense of isolation and helplessness, indicating a profound emotional and social disconnect. The client expresses feeling separated from others and scared, highlighting a deep emotional distress. Choices B, C, and D touch on different issues such as food insecurity, hopelessness about poverty, and lack of respect, but they do not specifically address the feelings of isolation and helplessness mentioned in the client's statement.

3. The healthcare professional is providing education on healthy eating habits to a group of adolescents. Which strategy is most likely to be effective?

• A. lecturing about the dangers of unhealthy eating
• B. distributing pamphlets on healthy food choices
• C. involving the adolescents in meal planning and preparation
• D. showing a documentary on the benefits of a healthy diet

Correct answer: C

Rationale: Involving adolescents in meal planning and preparation is a more effective strategy as it actively engages them in the learning process. This approach allows adolescents to have hands-on experience, make informed choices, and develop a sense of ownership over their dietary decisions. Lecturing about dangers or showing documentaries may not be as engaging or interactive, making it less likely for adolescents to retain and apply the information provided. Distributing pamphlets can be informative but lacks the interactive and experiential aspect that involving them in meal planning and preparation offers.

4. The nurse is developing a workshop on cancer prevention for a group of adults at a wellness bar. Which recommendation should the nurse include in the workshop?

• A. Know the four warning signs of cancer
• B. Maintain a healthy weight and exercise regularly
• C. Refrain from alcohol
• D. Obtain at least 6 to 10 hours of sleep per night

Correct answer: B

Rationale: Maintaining a healthy weight and exercising regularly are crucial recommendations in cancer prevention. These habits help reduce the risk of developing cancer by promoting overall health and reducing factors associated with cancer development. Knowing the warning signs of cancer (Choice A) is important for early detection but does not directly prevent cancer. While refraining from alcohol (Choice C) is beneficial for some cancers, it is not as universally applicable as maintaining a healthy weight and exercising. Getting adequate sleep (Choice D) is essential for overall health but is not as directly linked to cancer prevention as maintaining a healthy weight and regular exercise.

5. The wife of an older adult man who has had diabetes mellitus for the past 10 years reports to the home health nurse that her husband fell yesterday while taking his daily walk in the neighborhood. He has a bruised hand and a small abrasion on his left knee. The nurse assesses that his neurologic vital signs are stable. To reduce the risk for future falls, which assessment is most important for the nurse to obtain?

• A. current blood sugar level
• B. degree of paresthesia in feet
• C. wound healing of knee abrasion
• D. A1c glycosylated hemoglobin

Correct answer: B

Rationale: Assessing for paresthesia (numbness or tingling) in the feet is crucial in this scenario as it can help determine if the client has a loss of sensation, which increases the risk of falls. Paresthesia is a common complication of diabetes that can lead to decreased sensation and proprioception in the feet, contributing to balance issues and an increased risk of falls. Monitoring for paresthesia allows the nurse to assess the extent of sensory impairment and implement appropriate interventions to prevent future falls. While monitoring blood sugar levels (choice A) and A1c levels (choice D) are important in managing diabetes, in this case, assessing paresthesia takes precedence due to its direct impact on fall risk. Similarly, while monitoring the wound healing of the knee abrasion (choice C) is important for overall wound care, it is not directly related to reducing the risk of future falls in this situation.

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