Nursing Elites

1. What are the clinical manifestations of otitis media?

• A. Earache, wheezing, vomiting
• B. Coughing, rhinorrhea, headache
• C. Fever, irritability, pulling on ear
• D. Wheezing, cough, drainage in ear canal

Correct answer: C

Rationale: The correct answer is C: Fever, irritability, pulling on the ear. Clinical manifestations of otitis media commonly include fever, irritability, and children may show signs of pulling or rubbing their ears. Choices A, B, and D are incorrect. Choice A includes wheezing and vomiting, which are not typical symptoms of otitis media. Choice B includes coughing, rhinorrhea, and headache, which are more commonly associated with upper respiratory infections rather than otitis media. Choice D includes wheezing, cough, and drainage in the ear canal, which are not typical clinical manifestations of otitis media.

2. An older male client tells the nurse that he is losing sleep because he has to get up several times at night to go to the bathroom, that he has trouble starting his urinary stream, and that he does not feel like his bladder is ever completely empty. Which intervention should the nurse implement?

• A. Collect a urine specimen for culture analysis
• B. Review the client's fluid intake prior to bedtime
• C. Palpate the bladder above the symphysis pubis
• D. Obtain a fingerstick glucose level

Correct answer: C

Rationale: Palpating the bladder above the symphysis pubis is the most appropriate intervention in this scenario. It helps assess for urinary retention, which is a common issue in older males presenting with symptoms like difficulty starting urinary stream and feeling of incomplete bladder emptying. Collecting a urine specimen for culture analysis (Choice A) may be necessary in other situations like suspected urinary tract infection. Reviewing the client's fluid intake (Choice B) is important but does not directly address the current issue of urinary retention. Obtaining a fingerstick glucose level (Choice D) is not relevant to the client's urinary symptoms.

3. Which nursing intervention promotes achievement of the goal 'optimal mobility' for a client who had a total hip replacement 8 hours ago?

• A. Encourage the client to use an abductor pillow when ambulating.
• B. Teach the client to perform leg exercises in bed.
• C. Assist the client to sit at the edge of the bed.
• D. Assist the client to turn while an abductor pillow is between the legs.

Correct answer: D

Rationale: Assisting the client to turn while an abductor pillow is between the legs is the correct intervention to promote optimal mobility for a client who had a total hip replacement 8 hours ago. Using an abductor pillow helps maintain hip alignment and prevents dislocation, which are crucial considerations in the early postoperative period. Encouraging the client to use an abductor pillow when turning is more beneficial compared to the other options: teaching leg exercises in bed, encouraging the use of a walker when ambulating, or assisting the client to sit at the edge of the bed, as these interventions may not directly address the specific needs of a client after a total hip replacement.

4. Which instruction should the nurse provide a client who was recently diagnosed with Raynaud's disease?

• A. Avoid cold temperatures completely.
• B. Take medications only during flare-ups.
• C. Wear gloves when removing packages from the freezer.
• D. Limit physical activity to avoid stress.

Correct answer: C

Rationale: The correct instruction for a client with Raynaud's disease is to wear gloves when handling cold items to prevent vasospasm. Raynaud's disease is characterized by vasospasm in response to cold or stress, leading to reduced blood flow to extremities. Wearing gloves when removing packages from the freezer helps minimize exposure to cold temperatures and can prevent triggering vasospasms. Choices A, B, and D are incorrect. Avoiding cold temperatures completely is impractical and may not always be possible. Taking medications only during flare-ups does not address prevention strategies, and limiting physical activity to avoid stress is not a primary intervention for Raynaud's disease.

5. A young client who is being taught how to use an inhaler for symptoms of asthma tells the nurse about the intention to use the inhaler but plans to continue smoking cigarettes. In evaluating the client’s response, what is the best initial action by the nurse?

• A. Explain the risks of smoking with asthma.
• B. Revise the plan of care.
• C. Encourage the client to reduce smoking gradually.
• D. Provide resources for smoking cessation.

Correct answer: B

Rationale: The best initial action by the nurse is to revise the plan of care. This is necessary to address the client's intention to continue smoking and ensure that appropriate support and education are provided. Choice A is not the best initial action as the client is already aware of the risks of smoking with asthma. Choice C might not be effective as the client's intention to continue smoking poses a significant risk to their health. Choice D, providing resources for smoking cessation, is important but revising the plan of care should come first to address the immediate concern.

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