Nursing Elites

1. The client with Parkinson's disease spends over 1 hour to dress for scheduled therapies. What is the most appropriate action for the nurse to take in this situation?

• A. Ask family members to dress the client
• B. Encourage the client to dress more quickly
• C. Allow the client the time needed to dress
• D. Demonstrate methods on how to dress more quickly

Correct answer: C

Rationale: The most appropriate action for the nurse is to allow the client the time needed to dress. Patients with Parkinson's disease may experience difficulties with activities of daily living due to their condition. Allowing the client sufficient time to dress promotes independence and dignity, which are essential aspects of patient-centered care. Asking family members to dress the client may undermine the client's autonomy and self-esteem. Encouraging the client to dress more quickly may lead to frustration and feelings of inadequacy. Demonstrating methods on how to dress more quickly may not address the underlying challenges the client faces and could be perceived as insensitive or dismissive of the client's needs.

2. While assessing an Rh-positive newborn whose mother is Rh-negative, the nurse recognizes the risk for hyperbilirubinemia. Which of the following should be reported immediately?

• A. Jaundice evident at 26 hours
• B. Hematocrit of 55%
• C. Serum bilirubin of 12 mg/dL
• D. Positive Coombs test

Correct answer: C

Rationale: A serum bilirubin level of 12 mg/dL in a newborn is concerning and can indicate a significant risk of hyperbilirubinemia, which requires immediate medical intervention to prevent complications like kernicterus. Jaundice at 26 hours (Choice A) is a symptom, not a laboratory result, and needs monitoring but not an immediate report. Hematocrit of 55% (Choice B) may be elevated but is not indicative of hyperbilirubinemia. A positive Coombs test (Choice D) indicates the presence of antibodies on the newborn's red blood cells but does not directly correlate with the risk of hyperbilirubinemia.

3. A unit of Girl Scouts went hiking over Mt. Makiling. While resting, scout Jaymee, 14 years of age, complained of a sudden moderately bearable toothache. In checking their first-aid kit, they found none of mefenamic acid, BUT they luckily chanced upon a home that uses alternative pain-relieving medicinal plants. What would this plant be?

• A. Bawang
• B. Lagundi
• C. Sambong
• D. Tsaang gubat

Correct answer: A

Rationale: The correct answer is A, Bawang (garlic), which is traditionally used for its pain-relieving properties. While Lagundi, Sambong, and Tsaang gubat are also medicinal plants with various health benefits, they are not specifically known for their pain-relieving properties like garlic.

4. In a long term rehabilitation care unit a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television in the assigned room. Further assessment by the nurse reveals excessive sweating, a splotchy rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should do which action next?

• A. Take the client's respirations, blood pressure (BP), temperature and then pupillary responses
• B. Place the client into the bed and administer the ordered PRN analgesic
• C. Check the client for bladder distention and the client's urinary catheter for kinks
• D. Turn the television off and then assist client to use relaxation techniques

Correct answer: C

Rationale: These symptoms suggest autonomic dysreflexia, often triggered by bladder distention.

5. In planning for the nursing care of the sick person in the home, the major point that the nurse must keep in mind is:

• A. who will be responsible for the patient during the nurse's absence from the home
• B. economic level of the family
• C. the availability of the nearest hospital
• D. whether or not the patient is under a private physician

Correct answer: A

Rationale: The correct answer is A because ensuring someone is responsible for the patient is crucial for continuous care. The presence of a caregiver during the nurse's absence ensures the patient's safety and well-being. Choice B, economic level of the family, is important but not the major point when planning nursing care in the home. Choice C, the availability of the nearest hospital, is significant but doesn't address the day-to-day care in the home. Choice D, whether or not the patient is under a private physician, is relevant but not as critical as ensuring someone is available to care for the patient at all times.

Similar Questions