Nursing Elites

1. The nurse is caring for a 65-year-old client and notes a temperature of 101�F. How does the nurse interpret this finding?

• A. Hyperthermia
• B. A cold environment
• C. Normal
• D. Hypothermia

Correct answer: A

Rationale: A temperature of 101�F is indicative of hyperthermia, which is an elevated body temperature. Hyperthermia is commonly associated with fever or environmental factors such as excessive heat exposure. Choice B, 'A cold environment,' is incorrect as hyperthermia refers to elevated body temperature, not a cold environment. Choice C, 'Normal,' is incorrect as a temperature of 101�F is above the normal range for body temperature. Choice D, 'Hypothermia,' is incorrect as hypothermia refers to a low body temperature, not an elevated one.

2. Which finding is not typically associated with inflammation in a client?

• A. Pain
• B. Heat
• C. Polyuria
• D. Erythema

Correct answer: C

Rationale: Polyuria is excessive urination and is not a typical assessment finding in inflammation. Inflammation commonly presents with pain (A), heat (B), and erythema (D) which are classic signs of an inflammatory response. Pain results from the release of inflammatory mediators, heat is due to increased blood flow, and erythema is caused by vasodilation and increased blood flow to the area. Polyuria is more likely associated with conditions such as diabetes or renal issues, rather than inflammation.

3. The client has been asked to perform weight-bearing exercises three times a week. The client admits to not doing the recommended exercises. What is the most appropriate response by the nurse?

• A. I walk 3 miles every day. Would you like to join me?
• B. Tell me more about your experience with these exercises.
• C. My dad never exercised. He fell and broke his hip. Is that your goal?
• D. You should be doing these exercises.

Correct answer: B

Rationale: The most appropriate response by the nurse is to ask the client to elaborate on their experience with the exercises. By doing so, the nurse can gain insight into any barriers the client may be facing and work together to find solutions to improve adherence. Choice A is not appropriate as it doesn't address the client's situation. Choice C is not relevant and may induce fear in the client. Choice D is directive and does not promote open communication or understanding of the client's perspective.

4. The nurse will be using the Braden Scale with each admit to the long-term care center. Which of these will NOT be utilized in a Braden Scale Assessment?

• A. Mental state
• B. Friction and shear
• C. Nutrition
• D. Sensory perception

Correct answer: A

Rationale:

5. What health teaching would not help an older adult avoid a musculoskeletal injury?

• A. Avoid home modification
• B. Wear a helmet when riding a bicycle
• C. Osteoporosis screening
• D. Fall prevention

Correct answer: A

Rationale: Avoiding home modifications can increase the risk of falls and injuries in older adults.

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