Nursing Elites

1. When a client has a chest drainage system in place, where should the system be placed?

• A. above the level of the client's chest
• B. at the level of the client's shoulders
• C. at the level of the chest
• D. below the level of the chest

Correct answer: D

Rationale: A chest drainage system should be placed below the level of the client's chest to ensure proper drainage of fluid from the chest. Placing the system above the level of the chest or at the shoulders would not allow gravity to assist in the drainage process, potentially leading to complications such as fluid accumulation. Similarly, placing it at the level of the chest would not create the necessary gravity-dependent flow for effective drainage, which is crucial for the proper functioning of the chest drainage system.

2. Which is an appropriate outcome for the nursing diagnosis of Body Image Disturbance for a client with anorexia nervosa?

• A. The client verbalizes knowledge of a maintenance diet.
• B. The client demonstrates assertiveness with family.
• C. The client verbalizes her body size accurately.
• D. The client demonstrates control of obsessive behaviors.

Correct answer: C

Rationale: The correct answer is 'The client verbalizes her body size accurately.' For clients with anorexia nervosa, body image disturbance is a common issue where they perceive themselves inaccurately. Verbalizing her body size accurately indicates progress towards correcting this distorted self-perception. Choices A, B, and D are incorrect because they do not directly address the distorted body image perception seen in clients with anorexia nervosa. Choice A focuses on knowledge of a maintenance diet, which is unrelated to body image perception. Choice B involves assertiveness with family, which is more related to family dynamics. Choice D addresses control of obsessive behaviors, which is not directly related to correcting the distorted body image perception.

3. A client with cancer is transported to the radiology department for a bone scan to determine whether the cancer has metastasized to bone. While the client is in the radiology department, the client's wife arrives for a visit and asks what test is being performed on the client. What should the nurse tell the wife?

• A. A bone scan is being performed.
• B. She can read the client's medical record to determine what the health care provider prescribed.
• C. The radiology department is not clear as to which test has been prescribed.
• D. She will have to discuss the prescribed test with the client.

Correct answer: D

Rationale: In healthcare, confidentiality is crucial. Without the client's consent, nurses cannot disclose confidential information to anyone else, even to family members. Therefore, the appropriate response is to inform the client's wife that she will have to discuss the test with the client directly. It is not appropriate to disclose sensitive medical information without the client's permission. Offering the wife to read the medical record is a violation of privacy and confidentiality. Indicating that the radiology department is unclear about the prescribed test is inaccurate and does not uphold confidentiality. Moreover, it is not the responsibility of another department to disclose medical information; it is the duty of the healthcare provider and the client to discuss such matters.

4. Which of the following statements indicates adequate dietary understanding in a client with constipation?

• A. "I should decrease my intake of fluids."?
• B. "I should decrease my level of activity."?
• C. "I should increase my intake of apples."?
• D. "I should increase my intake of milk."?

Correct answer: C

Rationale: The correct answer is, "I should increase my intake of apples."? This statement indicates adequate dietary understanding in a client with constipation because apples are a good source of fiber, which helps alleviate constipation. Adequate fiber intake is essential for promoting bowel regularity. Choices A and B are incorrect as decreasing fluids and activity level can worsen constipation. Insufficient fluid intake can lead to hard stools, exacerbating constipation. Decreasing activity can also slow down bowel movements. Choice D is incorrect because milk is not a high-fiber food and may not effectively address constipation. While milk can have a mild laxative effect on some individuals, it is not a primary solution for constipation, especially when compared to high-fiber foods like apples.

5. Why might breast implants interfere with mammography?

• A. They might cause additional discomfort.
• B. They are contraindications to mammography.
• C. They are likely to be dislodged.
• D. They might prevent detection of masses.

Correct answer: D

Rationale: Breast implants can interfere with mammography by potentially preventing the detection of masses. The presence of implants can obscure a clear view of breast tissue, making it difficult to identify abnormalities such as masses that may indicate breast cancer. Choices A, B, and C are incorrect because discomfort, contraindications, and dislodgment are not primary reasons why breast implants interfere with mammography. The main concern is the impedance of detecting abnormalities accurately due to the implants.

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