Nursing Elites

1. The nurse is assessing an older adult client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding?

• A. Ptosis on the left eyelid.
• B. Nystagmus.
• C. Astigmatism.
• D. Exophthalmos.

Correct answer: A

Rationale: The correct answer is A: 'Ptosis on the left eyelid.' Ptosis is the term used to describe an eyelid droop that covers a large portion of the iris, which may be caused by issues with the oculomotor nerve or eyelid muscles. Choice B, 'Nystagmus,' refers to involuntary eye movements and is not related to eyelid drooping. Choice C, 'Astigmatism,' is a refractive error affecting vision due to an irregularly shaped cornea or lens, not an eyelid condition. Choice D, 'Exophthalmos,' is a protrusion of the eyeball associated with conditions like hyperthyroidism, not eyelid drooping.

2. The nurse identifies a client's needs and formulates the nursing problem of 'Imbalance nutrition: Less than body requirements, related to mental impairment and decreased intake, as evidenced by increasing confusion and weight loss of more than 30 pounds over the last 6 months.' Which short-term goal is best for this client?

• A. Eat 50% of six small meals each day by the end of the week.
• B. Gain 5 pounds by the end of the month.
• C. Have increased caloric intake.
• D. Show improved nutritional status.

Correct answer: A

Rationale: The correct short-term goal for the client in this scenario is option A: 'Eat 50% of six small meals each day by the end of the week.' This goal is specific, measurable, and time-bound, which aligns with the SMART criteria for goal setting in nursing care. It addresses the client's nutritional needs directly, focusing on increasing meal frequency to meet body requirements and counteract weight loss. Option B, 'Gain 5 pounds by the end of the month,' is not as suitable as it lacks specificity and a short-term timeline, making it less achievable within the immediate care plan. Option C, 'Have increased caloric intake,' is vague and does not provide a measurable target for the client to work towards. Option D, 'Show improved nutritional status,' is a broad goal that lacks the specificity needed for effective short-term goal setting in nursing care. Therefore, option A is the most appropriate choice for this client's short-term goal.

3. The school nurse is conducting an audit of incident reports for adolescent students. Which finding is the best indication that the Healthy People 2020 objectives are being addressed?

• A. the absenteeism rate has increased greatly over the past two years
• B. during the last year fewer firearms were retrieved on school property
• C. the number of requests for pregnancy testing is higher than last year
• D. decline in the number of students enrolled in school during the year

Correct answer: B

Rationale: The correct answer is B. A decrease in firearms retrieved on school property is a positive indication that the Healthy People 2020 objectives are being addressed. This finding suggests progress in reducing violence and improving safety in schools, which aligns with the goals of promoting overall health and safety among adolescents. Choices A, C, and D do not directly relate to the Healthy People 2020 objectives. Increased absenteeism, higher requests for pregnancy testing, and a decline in student enrollment do not necessarily reflect the specific health and safety goals outlined in Healthy People 2020.

4. A community health nurse is developing a program to reduce the incidence of teen pregnancy. Which strategy is most likely to be effective?

• A. Distribute free condoms at local high schools
• B. Offer comprehensive sex education classes
• C. Promote abstinence-only education
• D. Provide access to reproductive health services

Correct answer: B

Rationale: Comprehensive sex education has been shown to be more effective in reducing teen pregnancy rates compared to abstinence-only education. Providing comprehensive sex education equips teens with knowledge about safe sex practices, contraception methods, and healthy relationships, which empowers them to make informed decisions. Distributing free condoms and providing access to reproductive health services are important components, but without proper education, teens may not understand how to use these resources effectively. Promoting abstinence-only education limits information and may not address the reality of teen sexual behavior, potentially leading to higher pregnancy rates.

5. Prior to implementing a community health program targeting teenage smoking, which information is most important for the nurse to obtain?

• A. greater access to any healthcare provider
• B. allowance for early discharge
• C. Prevalence and patterns of smoking among teenagers
• D. approval by the network healthcare provider

Correct answer: C

Rationale: The most important information for the nurse to obtain before implementing a community health program targeting teenage smoking is the prevalence and patterns of smoking among teenagers. Understanding this data is crucial to tailor the program to the specific needs and behaviors of the target group, ensuring it addresses the root causes effectively. Choices A, B, and D are unrelated to the specific needs of the target group and do not provide essential information for designing an effective smoking cessation program for teenagers.

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