Nursing Elites

1. The healthcare provider is caring for a client with hypokalemia. Which assessment finding requires immediate intervention?

• A. Muscle weakness.
• B. Irregular heart rate.
• C. Increased urinary output.
• D. Decreased deep tendon reflexes.

Correct answer: D

Rationale: Decreased deep tendon reflexes are a critical finding in hypokalemia that indicates severe potassium deficiency affecting neuromuscular function. Immediate intervention is necessary to prevent life-threatening complications such as respiratory failure or cardiac arrhythmias. Muscle weakness, irregular heart rate, and increased urinary output are also associated with hypokalemia but do not pose the same level of urgency as decreased deep tendon reflexes.

2. A female client makes routine visits to a neighborhood community health center. The nurse notes that this client often presents with facial bruising, particularly around the eyes. The nurse discusses prevention of domestic violence with the client even though the client does not admit to it. What level of prevention has the nurse applied in this situation?

• A. primary prevention
• B. secondary prevention
• C. tertiary prevention
• D. health promotion

Correct answer: A

Rationale: The nurse has applied primary prevention in this situation. Primary prevention involves efforts to prevent the occurrence of domestic violence before it starts, even if the client does not admit to the abuse. Secondary prevention focuses on early detection and intervention to reduce the harm caused by violence that is already occurring. Tertiary prevention involves actions taken to rehabilitate and support individuals who have experienced domestic violence. Health promotion encompasses a broader approach aimed at improving overall health and well-being, which may include education on domestic violence prevention but is not specific to this scenario.

3. A client with a history of asthma is admitted with shortness of breath. Which assessment finding requires immediate intervention?

• A. Expiratory wheezes.
• B. Increased respiratory rate.
• C. Absence of breath sounds.
• D. Frequent coughing.

Correct answer: C

Rationale: The correct answer is C: Absence of breath sounds. This finding is concerning in a client with asthma as it may indicate a severe asthma exacerbation, airway obstruction, or pneumothorax, all of which require immediate intervention. Absence of breath sounds suggests a lack of airflow in the lungs, which is a critical sign that should prompt immediate action. Expiratory wheezes (choice A) are common in asthma and may not warrant immediate intervention unless severe. An increased respiratory rate (choice B) is expected in a client with asthma experiencing shortness of breath, but it does not indicate an immediate threat to the airway. Frequent coughing (choice D) is a common symptom in asthma exacerbations but does not signify an immediate need for intervention as it can be managed with appropriate asthma treatments.

4. During a home visit, the nurse observes that an elderly client has a cluttered living environment and poor lighting. What should the nurse do first?

• A. suggest that the client hires a cleaning service
• B. assist the client in organizing the living space
• C. assess the client's risk for falls
• D. provide the client with information on home safety

Correct answer: C

Rationale: The correct first action for the nurse to take is to assess the client's risk for falls. A cluttered living environment and poor lighting are significant risk factors for falls in the elderly. By assessing the client's risk for falls, the nurse can identify potential hazards and implement appropriate interventions to prevent falls. Suggesting hiring a cleaning service or assisting in organizing the living space may address the symptoms but not the root cause of the fall risk. Providing information on home safety is important but should come after assessing the specific risk factors for falls in this scenario.

5. 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.

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