Nursing Elites

1. The nurse will be using the Braden Scale with each admit to the long-term care center. Which of these will NOT be utilized in a Braden Scale Assessment?

• A. Mental state
• B. Friction and shear
• C. Nutrition
• D. Sensory perception

Correct answer: A

Rationale:

2. What is a negative effect of immobility on the cardiovascular system?

• A. Increased high density lipoprotein
• B. Increased circulation
• C. Increased pumping action of the heart
• D. Venous stasis

Correct answer: D

Rationale: Venous stasis is a negative effect of immobility on the cardiovascular system as it can lead to blood clots.

3. A client who had an elective below-the-knee amputation reports pain in the foot that was amputated. What is the best response by the nurse?

• A. The pain will go away after the swelling decreases.
• B. That is phantom limb pain.
• C. Your foot has been amputated, so you are not having pain in that foot.
• D. On a scale of 0-10, how would you rate your pain?

Correct answer: D

Rationale: The correct response is to assess the pain intensity by asking the client to rate their pain on a scale of 0-10. This helps the nurse to effectively manage the client's pain. Choice A is incorrect as it dismisses the client's pain without proper assessment. Choice B is incorrect as it assumes the pain is phantom limb pain without assessing the client's current condition. Choice C is incorrect as it invalidates the client's pain experience and does not address the issue at hand.

4. A wound has a blood-tinged liquid that is dripping from the surgical site. How does the nurse document this finding?

• A. Creamy pus
• B. Serous
• C. Serosanguineous
• D. Purulent exudate

Correct answer: C

Rationale:

5. A client does not understand why vision loss due to glaucoma is irreversible. What is the nurse's best explanation?

• A. Once retinal detachment occurs, it does not return to its normal state
• B. Once the tissue has necrosed from high-pressure, it does not regenerate
• C. Glaucoma always leads to permanent blindness
• D. Once bacterial infection has caused damage, the tissue does not regenerate

Correct answer: B

Rationale: The correct explanation for irreversible vision loss in glaucoma is that once the tissue has necrosed from high pressure, it does not regenerate. This necrosis occurs due to the damage caused by increased intraocular pressure, which leads to irreversible damage to the optic nerve and retinal tissue. Choices A, C, and D are incorrect because they do not directly address the specific mechanism of irreversible vision loss in glaucoma, which is necrosis due to high pressure.

Similar Questions