Nursing Elites

1. When performing an admission assessment of a client diagnosed with a brain tumor, which question is most important for the nurse to ask the client?

• A. When did your symptoms first begin?
• B. Can you describe the pain and how it feels?
• C. Do you have any changes in vision?
• D. Have you experienced any seizures?

Correct answer: D

Rationale: The correct answer is D. When assessing a client diagnosed with a brain tumor, asking about seizures is crucial because they can be a common symptom associated with brain tumors. Seizures in this context could provide valuable information regarding the progression and impact of the brain tumor on the client's neurological status. Choices A, B, and C are important questions in a general assessment, but when specifically focusing on a client with a brain tumor, inquiring about seizures takes priority due to its direct relevance to the condition.

2. When evaluating the preoperative teaching of a client scheduled for arthroscopic anterior cruciate ligament repair, which statement by the client indicates that the teaching was effective?

• A. I will use crutches to keep my weight off my knee
• B. I will stay home until a wheelchair is delivered
• C. I can use the trapeze bar and side rails on the bed to help me turn regularly
• D. I can put my full weight on my foot starting the day after surgery

Correct answer: A

Rationale: The correct answer is A. Using crutches indicates an understanding of weight-bearing restrictions post-surgery. Choice B is incorrect because waiting for a wheelchair is not related to postoperative mobility instructions. Choice C is incorrect as turning in bed using the trapeze bar and side rails does not address weight-bearing restrictions. Choice D is incorrect because putting full weight on the foot immediately after surgery contradicts the need to keep weight off the knee.

3. A child with Leukemia is admitted for chemotherapy, and the nursing diagnosis, altered nutrition, less than body requirements related to anorexia, nausea, vomiting is identified. Which intervention should the nurse include in this child's plan of care?

• A. Allow the child to eat foods desired and tolerated
• B. Restrict foods brought from fast food restaurants
• C. Recommend eating the same foods as siblings eat at home
• D. Encourage a variety of large portions of food at every meal

Correct answer: A

Rationale: The correct intervention for a child with Leukemia undergoing chemotherapy and experiencing altered nutrition, less than body requirements due to anorexia, nausea, and vomiting is to allow the child to eat foods desired and tolerated. This intervention helps improve the child's nutrition intake during chemotherapy. Choice B is incorrect because restricting foods may further limit the child's nutritional intake. Choice C is incorrect because recommending eating the same foods as siblings may not align with the child's preferences or needs during treatment. Choice D is incorrect as encouraging large portions of food at every meal may overwhelm the child and be counterproductive to their nutritional needs.

4. A client is taught how to collect a 24-hour urine specimen. Which statement indicates understanding of the procedure?

• A. I should keep the urine specimen refrigerated.
• B. I need to start the collection in the morning after my first void.
• C. I will collect the urine for 24 hours and keep it on ice.
• D. I will start collecting the urine after discarding my first morning specimen.

Correct answer: D

Rationale: The correct way to collect a 24-hour urine specimen is to discard the first morning void and then start the collection. Choice A is incorrect because refrigeration is not typically necessary for a 24-hour urine specimen. Choice B is incorrect as the client needs to discard the first void. Choice C is incorrect; while collecting urine for 24 hours is correct, keeping it on ice is not standard procedure.

5. A male client is admitted to the mental health unit because he experiences panic attacks when driving on the freeway. To attempt to desensitize this fear, what action should the nurse encourage the client to implement?

• A. Watch training videos of people driving in various environments
• B. Begin visualizing himself driving each route to the freeway
• C. Take antianxiety medication two hours before driving on freeways
• D. Get in the car with a support person and drive on a freeway during rush hour

Correct answer: B

Rationale: Visualization techniques, such as visualizing himself driving each route to the freeway, are commonly used in desensitization therapy to help clients gradually overcome their fears. Watching videos of others driving or taking medication do not actively involve the client in facing their fear, which is essential in desensitization therapy. Getting in the car with a support person during rush hour may exacerbate the client's anxiety rather than help in desensitization.

Similar Questions