Nursing Elites

1. What is the function of the epiglottis during swallowing?

• A. Prevents food from entering the trachea
• B. Aids in food propulsion
• C. Enhances taste sensation
• D. Lubricates the esophagus

Correct answer: A

Rationale: The epiglottis is a flap of tissue that closes over the trachea during swallowing to prevent food and liquids from entering the airway. Choice A is correct because the primary function of the epiglottis is to act as a lid over the trachea, ensuring that food goes down the esophagus and not into the windpipe. Choices B, C, and D are incorrect as they do not describe the specific role of the epiglottis during swallowing.

2. A homeless male client with a history of alcohol abuse had a CVA 10 years ago that resulted in left hemiparesis. Today he is brought to the clinic reporting pain in his left leg. He is afebrile, has 4+ pitting edema in the lower left leg, and has minimal swelling of the right leg. Which action should the PN implement first?

• A. Obtain a blood alcohol test
• B. Inspect legs for infection or trauma
• C. Complete a mental status exam
• D. Inquire about dietary salt intake

Correct answer: B

Rationale: Inspecting the legs for infection or trauma is the priority to assess the cause of the pain and edema, which could indicate deep vein thrombosis or cellulitis. Checking for signs of infection or trauma is crucial in this scenario to rule out potentially serious conditions. Obtaining a blood alcohol test, completing a mental status exam, or inquiring about dietary salt intake can be considered after addressing the immediate concern of identifying any infection or trauma in the leg.

3. The PN notes that a UAP is ambulating a male client who had a stroke and has right-sided weakness. The UAP is walking on the client's left side. Which action should the PN take?

• A. Instruct the UAP to walk on the client's affected side
• B. Take over the ambulation and provide guidance to the UAP immediately
• C. Provide the client with an assistive device, such as a cane or walker
• D. Tell the UAP to take the client back to his room

Correct answer: A

Rationale: The correct action for the PN to take is to instruct the UAP to walk on the client’s affected side. This is essential to provide the necessary support and prevent falls, especially when the client has weakness on one side due to a stroke. Walking on the affected side helps provide stability and assistance to the weaker side. Choice B is incorrect because it would be more appropriate for the PN to provide immediate guidance and correct the UAP's positioning rather than taking over the task completely. Choice C is incorrect because while assistive devices may be beneficial, the immediate concern is the UAP's positioning during ambulation, not providing the client with an assistive device. Choice D is incorrect as there is no indication to return the client to his room unless it is necessary for his safety or well-being.

4. The PN is caring for a client with schizophrenia who continues to repeat the last words heard. Which nursing problem should the PN document in the medical record?

• A. Altered thought processes
• B. Impaired social interaction
• C. Risk for self-directed violence
• D. Disturbed thought processes

Correct answer: D

Rationale: The correct answer is D: Disturbed thought processes. Echolalia, the repetition of heard words, is associated with disturbed thought processes, which are commonly seen in schizophrenia. Altered thought processes (Choice A) is a generic term and does not specifically address the behavior of repeating words. Impaired social interaction (Choice B) is not the primary concern when a client repeats the last words heard. Risk for self-directed violence (Choice C) is not directly related to the behavior of repeating words but focuses on the potential harm the client may cause to themselves.

5. The PN identifies an electrolyte imbalance, exhibited by changes in mental status, and an elevated blood pressure for a client with progressive heart disease. Which intervention should the PN implement first?

• A. Record usual eating patterns
• B. Evaluate for muscle cramping
• C. Document abdominal girth
• D. Elevate both legs on pillows

Correct answer: B

Rationale: Evaluating for muscle cramping, which is a sign of electrolyte imbalance, is crucial in this scenario. Electrolyte imbalances, especially involving potassium or calcium, can lead to serious complications such as arrhythmias or seizures, which need immediate attention. Recording eating patterns (choice A) may be important for overall assessment but is not the priority in this situation. Documenting abdominal girth (choice C) and elevating legs on pillows (choice D) are not directly related to addressing the immediate concern of electrolyte imbalance and its potential complications.

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