Nursing Elites

1. The healthcare provider is caring for a client with a history of hypertension. Which assessment finding would be most concerning?

• A. Blood pressure of 150/90 mmHg
• B. Irregular heart rate
• C. Shortness of breath
• D. Headache

Correct answer: C

Rationale: Shortness of breath in a client with a history of hypertension is a critical assessment finding as it may indicate heart failure, pulmonary edema, or other severe complications. The development of shortness of breath suggests that the client's condition may be rapidly deteriorating and requires immediate medical attention. Elevated blood pressure (150/90 mmHg) is concerning but not as acute as the potential complications associated with shortness of breath. An irregular heart rate and headache can also be symptoms of hypertension, but in this scenario, shortness of breath poses a higher risk of severe cardiovascular or respiratory issues.

2. How can the LPN/LVN best handle the situation of a postoperative client being kept awake by a neighboring client with dementia who sings all night?

• A. Tell the neighboring client to stop singing.
• B. Close the doors to both clients' rooms at night.
• C. Give the complaining client the prescribed sedative as needed.
• D. Move the neighboring client to a room at the end of the hall.

Correct answer: D

Rationale: The best way to handle the situation in this scenario is to move the neighboring client to a room at the end of the hall. This solution is considerate to both clients because it addresses the issue by providing a quieter environment for the client with dementia while allowing the postoperative client to rest. Choice A is inappropriate as it does not address the root cause of the problem and may not be feasible or respectful. Choice B of closing the doors may not effectively reduce the noise disturbance. Choice C of giving the complaining client sedatives should be the last resort and not the initial solution, as it does not address the underlying issue causing the disturbance.

3. A client is reporting pain to a nurse. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?

• A. "I'm having mild pain."
• B. "The pain is like a dull ache in my stomach."
• C. "I notice that the pain gets worse after I eat."
• D. "The pain makes me feel nauseous."

Correct answer: B

Rationale: The correct answer is B. When documenting the quality of pain, it is essential to record the client's description of how the pain feels in their own words. Choice A simply states the intensity of pain but does not describe its quality. Choices C and D provide information related to aggravating factors and associated symptoms, respectively, but they do not describe the quality of pain. Therefore, choice B, which describes the pain as a dull ache in the stomach, is the most appropriate statement to document for assessing the quality of the client's pain.

4. A client is expressing anger over his diagnosis of colorectal cancer. Which of the following actions should the nurse take?

• A. Discuss the risk factors for colorectal cancer.
• B. Focus teaching on addressing the client's anger and emotional response.
• C. Provide the client with emotional support and reassurance about his feelings.
• D. Reassure the client that this is an expected response to grief.

Correct answer: D

Rationale: The correct answer is D. During the anger stage of grief, it is essential for the nurse to reassure the client that anger is a normal reaction to a cancer diagnosis. This validation of the client's emotions can help in providing emotional support. Choice A is incorrect because discussing risk factors for colorectal cancer does not address the client's current emotional state. Choice B is incorrect because focusing teaching on the client's future management does not directly address the client's need for emotional support in the present. Choice C is incorrect because providing written information about loss and grief phases is not as immediately comforting as directly reassuring the client about his feelings of anger.

5. The patient is being taught about flossing and oral hygiene. What instruction will the nurse include in the teaching session?

• A. Using waxed floss helps prevent bleeding
• B. Flossing removes plaque and tartar from the teeth
• C. Flossing at least 3 times a day is beneficial
• D. Applying toothpaste before flossing is harmful

Correct answer: B

Rationale: The correct answer is B. Flossing is essential for removing plaque and tartar between teeth, contributing to better oral hygiene. Choice A is not entirely accurate as waxed floss may not solely prevent bleeding. Flossing three times a day, as mentioned in choice C, can be excessive and unnecessary, while choice D is incorrect as applying toothpaste before flossing is not harmful but might not provide additional benefits.

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