Nursing Elites

1. Why is it important to initiate nursing interventions that promote good nutrition, rest, exercise, and stress reduction for clients diagnosed with an HIV infection?

• A. Prevent the spread of infection to others
• B. Improve the function of the immune system
• C. Increase the ability to carry out activities of daily living
• D. Promote a feeling of general well-being

Correct answer: B

Rationale: The correct answer is B: 'Improve the function of the immune system.' Initiating interventions focusing on good nutrition, rest, exercise, and stress reduction aims to enhance the immune system function in clients with HIV infection. For individuals with HIV, maintaining a strong immune system is crucial in fighting the virus and preventing opportunistic infections. Choices A, C, and D are important aspects of care but are secondary to the primary goal of boosting the immune system to combat the effects of the HIV virus.

2. What should be the school nurse's first action after being notified that Child A has bitten Child B on the arm, resulting in broken skin but no bleeding?

• A. Apply antibiotic cream to Child B’s arm immediately
• B. Determine if Child A has a history of Hepatitis C or HIV
• C. Determine the date of Child B’s latest tetanus booster
• D. Wash Child B’s arm thoroughly with soap and water

Correct answer: D

Rationale: The correct first action for the school nurse to take in this situation is to wash Child B’s arm thoroughly with soap and water. Washing the wound immediately is crucial to reduce the risk of infection from the bite. Applying antibiotic cream may come after cleaning the wound. Determining Child A's medical history or checking Child B's tetanus status is important but not the immediate priority when dealing with a bite wound.

3. Following rectal surgery, a female client is very anxious about the pain she may experience during defecation. The nurse should collaborate with the healthcare provider to administer which type of medication?

• A. Bulk-forming agent
• B. Antianxiety agent
• C. Stool softener
• D. Stimulant cathartic

Correct answer: C

Rationale: After rectal surgery, a stool softener is the most appropriate medication to help prevent pain and straining during defecation. Stool softeners work by increasing the water content of the stool, making it easier to pass without discomfort. Bulk-forming agents (Choice A) help add mass to the stool but may not address the immediate post-operative discomfort. Antianxiety agents (Choice B) would address the anxiety but not the physical discomfort. Stimulant cathartics (Choice D) are not recommended after rectal surgery as they can cause cramping and increased bowel movements, potentially exacerbating pain.

4. Which intervention should the nurse include in the plan of care for a patient with tetanus?

• A. Open window shades to provide natural light
• B. Encourage coughing and deep breathing
• C. Minimize the amount of stimuli in the room
• D. Reposition from side to side every hour

Correct answer: C

Rationale: The correct intervention for a patient with tetanus is to minimize the amount of stimuli in the room. Tetanus can lead to muscle spasms and heightened sensitivity to stimuli, making it essential to reduce environmental triggers for the patient's comfort and safety. Opening window shades for natural light (Choice A) may exacerbate sensitivity to light and worsen symptoms. Encouraging coughing and deep breathing (Choice B) is not directly related to managing tetanus symptoms. While repositioning the patient every hour (Choice D) is important for preventing pressure ulcers, it is not the priority when managing tetanus, which requires a quiet, low-stimulus environment to minimize muscle spasms and discomfort.

5. The nurse is evaluating a client who has had a mastectomy and is experiencing pain and swelling in the arm on the affected side. What action should the nurse take?

• A. Assess for signs of lymphedema
• B. Encourage the client to perform arm exercises
• C. Provide pain relief through medication
• D. Recommend wearing a compression sleeve

Correct answer: A

Rationale: Assessing for signs of lymphedema is crucial in this situation as it is a common complication following mastectomy. Lymphedema presents as swelling and pain in the affected arm due to compromised lymphatic drainage. By assessing for lymphedema, the nurse can identify the condition early and implement appropriate interventions such as compression sleeves, manual lymphatic drainage, and exercises. Encouraging arm exercises (Choice B) may exacerbate the symptoms if lymphedema is present. While providing pain relief through medication (Choice C) is important, assessing for the underlying cause of pain and swelling takes precedence. Recommending a compression sleeve (Choice D) may be suitable but should come after a thorough assessment for lymphedema to ensure the most effective management plan.

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