Nursing Elites

1. What is the priority nursing diagnosis for a client with immobility?

• A. Constipation related to immobility
• B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
• C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
• D. Risk for disuse syndrome as evidenced by immobility

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.

2. The nurse is caring for a client with rheumatoid arthritis one day after shoulder surgery. What would prompt the nurse to call the provider immediately?

• A. The client refused her pain medication this morning and is doing physical therapy.
• B. The client reports a minor headache and states she takes an over-the-counter pain pill at home.
• C. The client reports intermittent flatus and minor abdominal discomfort.
• D. The client has paresthesia in her fingers and intense increasing pain in her shoulder.

Correct answer: D

Rationale: In a client with rheumatoid arthritis one day after shoulder surgery, paresthesia in the fingers and intense increasing pain in the shoulder could indicate nerve compression or damage, which are serious post-operative complications. This situation requires immediate attention from the provider to prevent further complications and ensure appropriate management. The other options, such as refusing pain medication, reporting a minor headache, or experiencing minor abdominal discomfort, are important but not as urgent or indicative of potential serious complications as paresthesia in the fingers and intense increasing pain in the shoulder.

3. What does CREST stand for?

• A. Calcinosis, Raynaud's, Esophageal dysmotility, Sclerodactyly and Telecines
• B. Calcinosis, Reverse isolation, Esophageal dysmotility, Sclerodactyly and Telangiectasia
• C. Calcinosis, Raynaud's, Everted colon, Sclerodactyly and Telangiectasia
• D. Calcinosis, Raynaud's Esophageal dysmotility, Sclerodactyly and telangiectasia

Correct answer: D

Rationale:

4. During a skin inspection at the outpatient clinic, the nurse notices patches of thick, red skin with silvery scales on the client's elbows and knees. What skin abnormality does the nurse suspect?

• A. Scabies
• B. Rosacea
• C. Psoriasis
• D. Statis dermatitis

Correct answer: C

Rationale:

5. A nurse is admitting a client who has tuberculosis. What transmission-based precautions should the nurse initiate?

• A. Droplet
• B. Contact
• C. Airborne
• D. Protective

Correct answer: C

Rationale:

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