Nursing Elites

1. The nurse is caring for a client with status epilepticus. The most important nursing assessment of this client is

• A. Intravenous fluid infusion
• B. Level of consciousness
• C. Pulse and respirations
• D. Extremities for injuries

Correct answer: B

Rationale: In status epilepticus, the most crucial nursing assessment is the level of consciousness. Assessing the client's level of consciousness is vital as prolonged seizures can result in hypoxia, brain damage, and require immediate intervention. Pulse and respirations (choice C) are important assessments, but in status epilepticus, the priority is to monitor the client's neurological status. Checking intravenous fluid infusion (choice A) and extremities for injuries (choice D) are not the primary assessments needed in managing a client experiencing status epilepticus.

2. 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.

3. The emphasis of community health nursing is on:

• A. treatment of health problems
• B. preventing problems and promoting optimum health
• C. identification and assessment of health problems
• D. illness end of the wellness-illness continuum

Correct answer: B

Rationale: Community health nursing primarily focuses on preventive measures and promoting overall health within a community. Choice A is incorrect as treatment is not the main emphasis. Choice C is incorrect as identification and assessment are steps that may be involved but not the main focus. Choice D is incorrect as it refers to the illness end rather than the preventive end of the wellness-illness continuum.

4. Following-up Mrs. Luy, G5P4, you notice her eldest son is underweight and her youngest daughter looks thin and pale. Mrs. Luy's present pregnancy would mean another additional member of the family. This can be considered as:

• A. health deficit
• B. health deficit and health threat
• C. health threat
• D. foreseeable crisis

Correct answer: C

Rationale: The correct answer is C: 'health threat.' The new pregnancy poses a health threat due to the potential strain on resources and the existing issues with the children, such as underweight and being pale. Choice A is incorrect as it does not fully capture the potential risks associated with the new pregnancy. Choice B is also incorrect as it includes 'health deficit,' which is not explicitly mentioned in the scenario. Choice D, 'foreseeable crisis,' is not the most fitting description of the situation presented.

5. The nurse is evaluating the effectiveness of a community health program aimed at reducing teen pregnancy rates. Which outcome indicates the program was successful?

• A. increased attendance at health education classes
• B. decreased number of repeat pregnancies among teens
• C. higher number of teens seeking prenatal care
• D. greater use of contraception among teens

Correct answer: D

Rationale: The correct answer is D: greater use of contraception among teens. This outcome indicates successful prevention of pregnancies by demonstrating that teens are taking proactive steps to avoid unintended pregnancies. Increased attendance at health education classes (choice A) may show improved knowledge but does not directly measure the prevention of pregnancies. While a decreased number of repeat pregnancies among teens (choice B) is positive, it does not necessarily indicate prevention of initial pregnancies. A higher number of teens seeking prenatal care (choice C) is important for maternal and fetal health but does not directly reflect the prevention of teen pregnancies.

Similar Questions