Nursing Elites

1. What is the primary purpose of the logrolling technique for turning?

• A. To decrease the risk of back injury by working together.
• B. To maintain straight spinal alignment.
• C. To increase client safety by using two or three people.
• D. To reduce the likelihood of skin damage by turning instead of pulling.

Correct answer: B

Rationale: The correct answer is B: To maintain straight spinal alignment. Logrolling is a technique used to carefully turn a client while keeping the spine in a straight line, especially important for those with spinal injuries or after back surgery. Choice A is incorrect because the primary purpose is not specifically to decrease the risk of back injury but to ensure safe turning. Choice C is incorrect as the main aim is not to increase client safety by using multiple people but to protect the spine. Choice D is incorrect because the primary purpose of logrolling is not to prevent skin damage but to safeguard the spine during turning.

2. A client on long-term corticosteroid therapy for rheumatoid arthritis presents with weakness and hypotension. What is the nurse's first action?

• A. Administer a PRN dose of corticosteroids.
• B. Place the client in a supine position.
• C. Encourage oral fluid intake.
• D. Review the client's recent medication history.

Correct answer: A

Rationale: Administering a PRN dose of corticosteroids is the correct first action when a client on long-term corticosteroid therapy presents with weakness and hypotension. In this scenario, the client is likely experiencing adrenal insufficiency due to prolonged corticosteroid use. Administering corticosteroids promptly can help correct this insufficiency and improve the client's symptoms. Placing the client in a supine position may be necessary for symptomatic hypotension, but addressing the root cause with corticosteroids is more crucial initially. Encouraging oral fluid intake is important for many conditions but is not the priority in this case. Reviewing the client's recent medication history can provide valuable information but is not the first action needed to address the client's current presentation.

3. The nurse is performing a functional assessment for a client requiring nursing home care. Which action should the nurse implement?

• A. Question the client about the frequency of falls.
• B. Request the client to lie still during the assessment.
• C. Ask how often episodes of sundowning are experienced.
• D. Assist the client with values clarification about end-of-life care.

Correct answer: A

Rationale: The correct answer is A: Question the client about the frequency of falls. In the elderly population, falls are a significant risk factor that can impact their functional abilities and safety. By assessing the frequency of falls, the nurse can identify potential risks and implement interventions to prevent future falls. Choices B, C, and D are incorrect because they do not directly address the primary focus of a functional assessment for nursing home care, which is to evaluate the client's functional status and identify areas that may require assistance or intervention.

4. A client recently started on warfarin therapy. What laboratory value is most important to monitor for this client?

• A. Platelet count
• B. Prothrombin time (PT)
• C. Creatinine level
• D. Blood urea nitrogen (BUN)

Correct answer: B

Rationale: Prothrombin time (PT) is the most important laboratory value to monitor for clients on warfarin therapy. PT helps determine how long it takes blood to clot and ensures the warfarin dose is within the therapeutic range to prevent either excessive bleeding or clotting. Monitoring platelet count is important for assessing the risk of bleeding, but PT is more specific to warfarin therapy. Creatinine level and BUN are indicators of kidney function and are not directly related to warfarin therapy.

5. A client with schizophrenia is experiencing paranoia. What is the nurse's priority intervention?

• A. Reassure the client that their fears are unfounded.
• B. Place the client in a private room to reduce stimuli.
• C. Provide the client with a distraction to redirect their attention.
• D. Encourage the client to express their concerns and validate their feelings.

Correct answer: D

Rationale: Encouraging clients with paranoia to express their concerns and validating their feelings is crucial as it helps establish trust and reduce anxiety. This approach also aids in building a therapeutic relationship. Reassuring the client that their fears are unfounded (Choice A) may invalidate their feelings and worsen trust. Placing the client in a private room to reduce stimuli (Choice B) may be helpful in some situations but does not address the underlying issue of paranoia. Providing a distraction (Choice C) may temporarily shift the client's focus but does not address the root cause of the paranoia. Therefore, the priority intervention is to encourage the client to express their concerns and validate their feelings.

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