Nursing Elites

1. The nurse is caring for a client who develops compartment syndrome from a severely fractured arm. The client asks how this can happen. What is the best response by the nurse?

• A. . "The fascia expands with injury, causing pressure on underlying nerves and muscles."?
• B. "An injured artery causes impaired arterial perfusion through the compartment."?
• C. "Bleeding and swelling cause increased pressure in an area that cannot expand."?
• D. . "A bone fragment has injured the nerve supply in the area."?

Correct answer: C

Rationale:

2. What is the priority nursing diagnosis for a client with immobility?

• A. Constipation related to immobility
• B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
• C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
• D. Risk for disuse syndrome as evidenced by immobility

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.

3. What is accurate health promotion teaching to prevent ear infection or trauma? (Select all that apply)

• A. Blow nose gently without blocking nostrils
• B. Wear hearing protection when exposed to loud noise
• C. Avoid using cotton-tipped applicators to clean the external ear
• D. All of the above

Correct answer: D

Rationale: The correct health promotion teachings to prevent ear infection or trauma include blowing the nose gently without blocking nostrils, wearing hearing protection when exposed to loud noise, and avoiding the use of cotton-tipped applicators to clean the external ear. Blocking one nostril when blowing the nose is incorrect, as it can cause problems. Therefore, choice A is inaccurate. Additionally, using cotton-tipped applicators to clean the external ear can lead to trauma or infection, making choice C a correct preventive measure.

4. A client is diagnosed with systemic sclerosis (scleroderma). What symptoms is the first to occur?

• A. Tachycardia
• B. Raynaud's phenomenon
• C. Intense wrinkle
• D. Joint pain

Correct answer: B

Rationale:

5. A nurse is assessing a client with hallux valgus. What is another term for this assessment finding?

• A. Thoracic deformity
• B. A bunion
• C. A corn
• D. Metacarpal involvement

Correct answer: B

Rationale: Hallux valgus is commonly known as a bunion, which is a bony bump that forms on the joint at the base of the big toe. A) Thoracic deformity is unrelated to hallux valgus. C) A corn is a thickened area of skin on the foot, not synonymous with hallux valgus. D) Metacarpal involvement refers to the hand, not the foot where hallux valgus occurs.

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