Nursing Elites

1. Which of the following activities would the nurse perform during the diagnosing phase of the nursing process? Select all that apply.

• A. Collect and organize client information
• B. Analyze data
• C. Identify problems, risks, and client strengths
• D. Develop nursing diagnoses

Correct answer: B

Rationale: During the diagnosing phase of the nursing process, the nurse analyzes the collected data to identify problems, risks, and client strengths, which then leads to developing nursing diagnoses. Collecting and organizing client information is part of the assessment phase, where data is gathered. Developing nursing diagnoses comes after data analysis in the diagnosing phase. Goal setting is a component of the planning phase, which follows the diagnosing phase.

2. Assuming that an elderly patient will have a difficult time understanding the directions for how to take medication is an example of:

• A. Prejudice
• B. Stereotyping
• C. Encoding
• D. Rationalization

Correct answer: B

Rationale: Stereotyping is defined as providing a generalization about a person based on their culture or characteristics. In this scenario, assuming that an elderly patient will have difficulty understanding medication directions solely based on their age is an act of stereotyping. The healthcare provider is attributing a generalized trait to the patient without considering individual differences. Prejudice, on the other hand, involves forming a negative opinion about someone based on their heritage or culture, which is not evident in this situation. Encoding refers to the process of converting information into a form that can be stored in memory, and rationalization involves justifying one's behavior or decisions with logical reasons, neither of which are applicable in this context.

3. A client has applied a cold pack to their arm to help decrease swelling and inflammation after an injury. Which of the following signs indicates that the cold pack should be removed?

• A. The skin on the arm appears mottled
• B. The cold pack has been in place for 10 minutes
• C. The client complains of feeling nauseated
• D. The capillary refill in the area distal to the arm is 2 seconds

Correct answer: A

Rationale: When using a cold pack for therapeutic purposes, it is essential to monitor the site to prevent tissue damage. Prolonged use of cold therapy can lead to pale, mottled skin with a bluish appearance. This change in skin color indicates poor circulation, and the cold pack should be removed immediately to prevent tissue injury. Choices B, C, and D are incorrect because the duration of cold pack application, client complaints of nausea, and capillary refill time do not specifically indicate the need for the cold pack to be removed due to potential tissue damage.

4. A patient is diagnosed with essential hypertension. Which of the following blood pressures would you expect to see in this patient prior to taking medications for the condition?

• A. 142/92
• B. 118/72
• C. 120/80
• D. 138/88

Correct answer: A

Rationale: Before starting medications for essential hypertension, a patient would typically present with a blood pressure reading equal to or greater than 140/90. This indicates high blood pressure and is characteristic of essential hypertension. Choice A, 142/92, falls within this range, making it the correct answer. Choices B (118/72), C (120/80), and D (138/88) all have blood pressure readings that are within the normal range and would not typically be expected in a patient diagnosed with essential hypertension. Therefore, choices B, C, and D are incorrect as they do not align with the elevated blood pressure levels seen in essential hypertension.

5. Intermittent fevers are:

• A. fevers which come and go.
• B. fevers which rise and fall but are always considered above the patient's average temperature.
• C. fevers which fluctuate more than three degrees and never return to normal.
• D. None of the above.

Correct answer: A

Rationale: Intermittent fevers are characterized by periods of fever followed by periods of normal body temperature. They alternate between being febrile and afebrile. Continuous fevers show minimal fluctuations over a 24-hour period, while remittent fevers fluctuate significantly but do return to normal body temperature. Choice A is correct as it accurately describes intermittent fevers. Choices B and C are incorrect as they do not fully capture the defining characteristic of intermittent fevers, which involve cyclical episodes of fever and normal temperature. Choice D is incorrect as there is a specific definition for intermittent fevers.

Similar Questions