Nursing Elites

1. The nurse is caring for an 80-year-old client with Parkinson's disease. Which of the following nursing goals is MOST realistic and appropriate in planning care for this client?

• A. Facilitate the client in returning to usual activities of daily living
• B. Maintain optimal function within the client's limitations
• C. Assist the client in preparing for a peaceful and dignified death
• D. Delay the progression of the disease process in the client

Correct answer: B

Rationale: Maintaining optimal function within the client's limitations is the most realistic and appropriate nursing goal when caring for an 80-year-old client with Parkinson's disease. This goal focuses on maximizing the client's abilities and quality of life while acknowledging the impact of the disease. Option A is less realistic as returning to usual activities may not always be achievable in the case of Parkinson's disease. Option C is not appropriate as it does not address the client's current condition and care needs. Option D is less realistic as Parkinson's disease is progressive, and delaying its progression may not be entirely feasible.

2. A nurse is caring for a client who is being discharged home following a cerebrovascular accident. Which of the following documents should the nurse plan to include with the discharge report?

• A. List of prescribed medications
• B. Potential complications to report
• C. Family contact details
• D. Dietary restrictions

Correct answer: B

Rationale: The correct answer is B: Potential complications to report. Including potential complications in the discharge report is crucial for ensuring proper follow-up care. This information helps the client and their caregivers to be aware of warning signs that may indicate a worsening condition or the need for immediate medical attention. Choices A, C, and D are important aspects of discharge planning, but providing a list of potential complications to report takes precedence as it directly impacts the client's safety and well-being post-discharge.

3. Which of the following is an early indication that a tracheostomy client requires suctioning?

• A. Bradycardia
• B. Irritability
• C. Hypotension
• D. Decreased respiratory rate

Correct answer: B

Rationale: Irritability is indeed an early sign that a tracheostomy client may require suctioning. When a tracheostomy client becomes irritable, it can indicate that there is a need for suctioning to clear the airway. Bradycardia (choice A) refers to a slow heart rate and is not typically a direct indication for suctioning. Hypotension (choice C) indicates low blood pressure and is not specifically related to the need for suctioning. Decreased respiratory rate (choice D) can be a sign of respiratory distress, but irritability is a more direct and early indication of the need for suctioning in a tracheostomy client.

4. A client has developed phlebitis at the IV site. What should the nurse do first?

• A. Apply a warm compress to the IV site
• B. Discontinue the IV and notify the provider
• C. Monitor the IV site for signs of infection
• D. Administer an anti-inflammatory medication

Correct answer: B

Rationale: When a client develops phlebitis at the IV site, the priority action for the nurse is to discontinue the IV and notify the provider. Phlebitis is inflammation of the vein, and removing the IV can help prevent further complications. Applying a warm compress may provide symptomatic relief but does not address the root cause. Monitoring for infection is important, but immediate action to remove the source of inflammation is crucial. Administering an anti-inflammatory medication is not the first-line intervention for phlebitis; removal of the IV is necessary.

5. What are the key factors in assessing a patient's fall risk?

• A. Assess the patient's age and mobility
• B. Evaluate the patient's medication list for sedatives
• C. Assess the patient's vision and hearing
• D. Check for recent falls and cognitive impairment

Correct answer: A

Rationale: The correct answer is A. Assessing the patient's age and mobility are key factors in determining fall risk. Age can affect balance and reaction time, while mobility influences the patient's stability. Choices B, C, and D are important considerations in assessing a patient's fall risk as well, but age and mobility play a more direct role in determining the patient's susceptibility to falls.

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