Nursing Elites

1. The nurse is caring for a 75-year-old client in congestive heart failure. Which finding suggests that digitalis levels should be reviewed?

• A. Extreme fatigue
• B. Increased appetite
• C. Intense itching
• D. Constipation

Correct answer: A

Rationale: Extreme fatigue can be a sign of digitalis toxicity, especially in older adults, and warrants a review of the client's medication levels and potential adjustment. Increased appetite, intense itching, and constipation are not typically associated with digitalis toxicity and do not directly indicate a need for a review of digitalis levels.

2. When assisting a family who fails to take action during a sick member despite suggestions, you will:

• A. explain the consequences of inaction
• B. identify the courses of action open to the family and the resources needed for each
• C. discuss the consequences of each course of action available
• D. influence the family to act on what you think is best for the situation

Correct answer: B

Rationale: When helping a family decide on actions to take, it is essential to identify the courses of action available to them and the resources needed for each. This empowers the family to make informed decisions based on their specific situation. Explaining the consequences of inaction (Choice A) may be necessary but does not provide a range of options. Discussing the consequences of each course of action (Choice C) is important but does not actively guide the family on the available actions. Influencing the family (Choice D) to act based on personal judgment undermines their autonomy and may not lead to the best outcome.

3. What is the main focus of secondary prevention?

• A. Early detection and treatment
• B. Rehabilitation
• C. Health promotion
• D. Palliative care

Correct answer: A

Rationale: The main focus of secondary prevention is early detection and treatment of disease. This approach aims to identify health conditions in their early stages when they are easier to treat or manage effectively. Choice B, rehabilitation, is more aligned with restoring function after an illness or injury has occurred. Choice C, health promotion, concentrates on educating and empowering individuals to adopt healthy behaviors to prevent the onset of diseases. Choice D, palliative care, is focused on providing comfort and improving the quality of life for individuals with serious illnesses or at the end of life, rather than on early detection and treatment.

4. A client with HIV/AIDS is receiving zidovudine (Retrovir). The nurse should monitor the client for which of the following adverse effects?

• A. Hyperglycemia
• B. Anemia
• C. Hypertension
• D. Hypercalcemia

Correct answer: B

Rationale: The correct answer is B: Anemia. Zidovudine (Retrovir) can cause bone marrow suppression, leading to anemia. Monitoring for signs of anemia, such as fatigue, pallor, and shortness of breath, is crucial. Choice A, Hyperglycemia, is not a common adverse effect of zidovudine. Choice C, Hypertension, is not directly associated with zidovudine use. Choice D, Hypercalcemia, is also not a typical adverse effect of zidovudine.

5. The multidisciplinary home health care team is discussing a female client diagnosed with Parkinson's disease. The home health care nurse reports the client is getting worse, and her husband is no longer able to care for her in the home. Which action should the home health nurse implement first?

• A. Request a chaplain to counsel the couple.
• B. Assign a home health care aide to provide daily care.
• C. Discuss placing the wife in a nursing home with the husband.
• D. Contact the client's children to discuss the situation.

Correct answer: B

Rationale: In situations where a client's condition worsens and the caregiver is no longer able to provide sufficient care, the first action to implement is to assign a home health care aide to provide daily care. This ensures that the client's immediate needs are met and that they receive proper care and support. Requesting a chaplain for counseling (Choice A) may be beneficial but is not the most urgent action. Discussing placing the wife in a nursing home (Choice C) should only be considered after assessing the client's needs and exploring all other options. Contacting the client's children (Choice D) can be helpful but does not address the immediate need for daily care that the client requires.

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