Nursing Elites

1. The healthcare professional is taking the health history of a patient being treated for sickle cell disease. After being told the patient has severe generalized pain, the healthcare professional expects to note which assessment finding?

• A. Severe and persistent diarrhea
• B. Intense pain in the toe
• C. Yellow-tinged sclera
• D. Headache

Correct answer: C

Rationale: In patients with sickle cell disease, severe generalized pain can be associated with vaso-occlusive crises, but yellow-tinged sclera is a common clinical finding related to sickle cell disease. This yellowing of the sclera, known as jaundice, occurs due to the release of bilirubin from damaged or destroyed red blood cells. Severe and persistent diarrhea is not a typical assessment finding in sickle cell disease. Intense pain in the toe may be associated with vaso-occlusive crisis but is not the expected assessment finding in this scenario. Headache is a common symptom in many conditions but is not specifically related to the assessment finding expected in a patient with sickle cell disease presenting with severe generalized pain.

2. The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs two (2) hours ago. The nurse should

• A. Place a call to the client's healthcare provider for instructions
• B. Send him to the emergency room for evaluation
• C. Reassure the client's wife that the symptoms are transient
• D. Instruct the client's wife to call the doctor if his symptoms become worse

Correct answer: B

Rationale: In this scenario, the client is presenting with concerning symptoms of lethargy and confusion after a fall. These symptoms could indicate a serious underlying issue, such as a head injury or internal bleeding. The nurse's priority is to ensure the client receives immediate evaluation and treatment to prevent any further harm. Option B is the correct choice as it emphasizes the urgency of the situation. Choices A, C, and D are incorrect because they do not address the critical nature of the client's condition. Contacting the healthcare provider, reassuring the wife, or waiting for symptoms to worsen could delay necessary medical intervention.

3. A 38-year-old patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care?

• A. Restrict daily dietary protein intake.
• B. Reposition the patient every 4 hours.
• C. Place the patient on a pressure-relieving mattress.
• D. Perform passive range of motion daily.

Correct answer: C

Rationale: Placing the patient on a pressure-relieving mattress is crucial to decrease the risk of skin breakdown, especially with significant edema and ascites. Adequate dietary protein intake is essential in patients with ascites to improve oncotic pressure and prevent malnutrition. Repositioning the patient every 4 hours alone may not be sufficient to prevent skin breakdown, especially in areas prone to pressure ulcers. Performing passive range of motion exercises is important for maintaining joint mobility but does not directly address the risk of skin breakdown associated with prolonged pressure on vulnerable areas.

4. A victim of domestic violence states, 'If I were better, I would not have been beaten.' Which feeling best describes what the victim may be experiencing?

• A. Fear
• B. Helplessness
• C. Self-blame
• D. Rejection

Correct answer: C

Rationale: The correct answer is self-blame. In this scenario, the victim is attributing the abuse to their own inadequacies or faults, thinking that if they were different, the abuse would not occur. This is a common response seen in victims of domestic violence, where they wrongly internalize the blame for the abuser's actions. Fear (Choice A) is a valid emotion, but in this case, the victim is not expressing fear but rather self-blame. Helplessness (Choice B) is also a common feeling in victims of domestic violence, but in this specific statement, the victim is demonstrating self-blame. Rejection (Choice D) does not accurately reflect the victim's statement and emotional response in the given scenario.

5. The physician has decided to perform a thoracentesis based on Mr. R's assessment. Which of the following actions from the nurse is most appropriate?

• A. Instruct the client not to talk during the procedure
• B. Assist the client to sit upright or slightly lean forward
• C. Insert a 20-gauge needle just above the 4th intercostal space
• D. Connect the needle to suction to remove fluid that has collected in the pleural space

Correct answer: A

Rationale: The correct answer is to instruct the client not to talk during the procedure. This is important to prevent air from being drawn into the pleural space during the thoracentesis. Choice B is incorrect because the client should be sitting upright or slightly leaning forward during the procedure to facilitate access to the pleural space. Choice C is incorrect as the nurse should not perform the thoracentesis procedure, which involves inserting a needle into the pleural space - this is the physician's responsibility. Choice D is incorrect as connecting the needle to suction to remove fluid is not the appropriate procedure for a thoracentesis. Thoracentesis is typically done to remove fluid or air for diagnostic or therapeutic purposes, not to connect to suction to remove fluid that has collected in the pleural space.

Similar Questions