Nursing Elites

1. Which client has the highest risk for developing community-acquired pneumonia?

• A. a 40-year-old first-grade teacher who works with underprivileged children
• B. a 75-year-old retired secretary with exercise-induced wheezing
• C. a 60-year-old homeless person who is an alcoholic and smokes
• D. a 35-year-old aerobics instructor who skips meals and eats only vegetables

Correct answer: C

Rationale: The correct answer is C because homeless individuals who are alcoholics and smoke have a higher risk of developing community-acquired pneumonia due to factors like poor living conditions, compromised immune systems, and increased exposure to infections. Choice A is less likely as the teacher's profession, while involving contact with children, may not pose as high a risk as the factors in choice C. Choice B may have respiratory issues but does not have the same risk factors as choice C. Choice D, the aerobics instructor, may have a healthy lifestyle but skipping meals and a restrictive diet do not directly correlate with a higher risk of pneumonia compared to the risk factors in choice C.

2. The client with asthma who is sensitive to house dust-mites is being instructed by the nurse. Which information about prevention of asthma episodes would be the most helpful to include during the teaching?

• A. Change the pillow covers every month
• B. Wash bed linens in warm water with a cold rinse
• C. Wash and rinse the bed linens in hot water
• D. Use air filters in the furnace system

Correct answer: C

Rationale: The correct answer is to wash and rinse the bed linens in hot water to help eliminate dust mites, a common trigger for asthma episodes. Washing in hot water is more effective in killing dust mites compared to warm water. Changing pillow covers every month may help but is not as effective as washing bed linens in hot water. Using air filters in the furnace system may improve air quality but does not directly target dust mites on bed linens.

3. A hospitalized child suddenly has a seizure while his family is visiting. The nurse notes whole body rigidity followed by general jerking movements. The child vomits immediately after the seizure. A priority nursing diagnosis for the child is

• A. High risk for infection related to vomiting
• B. Altered family processes related to chronic illness
• C. Fluid volume deficit related to vomiting
• D. Risk for aspiration related to loss of consciousness

Correct answer: D

Rationale: Risk for aspiration is a priority concern following a seizure, especially when the child vomits, as there is a danger of aspirating the vomit into the lungs, leading to respiratory complications. The other options are not the priority in this situation. While infection risk and fluid volume deficit are important, ensuring the child's airway is clear and there is no risk of aspiration takes precedence. Altered family processes may be a concern but addressing the immediate physiological risk is the priority.

4. In formulating an objective of a community care plan, she expected results and people taking part in the activities should be clearly defined. This refers to an objective which is:

• A. time-bound
• B. specific
• C. resource-oriented
• D. measurable

Correct answer: B

Rationale: The correct answer is 'specific.' In formulating a community care plan, defining expected results and participant roles require objectives to be specific to provide clear guidance and outcomes. 'Time-bound' refers to setting deadlines, 'resource-oriented' focuses on utilizing available resources efficiently, and 'measurable' indicates the ability to quantify progress, but these aspects do not necessarily address the need for clarity and definition in defining expected results and participant roles.

5. The nurse is administering the measles, mumps, rubella (MMR) vaccine to a 12-month-old child during the well-baby visit. Which age range should the nurse advise the parents to plan for their child to receive the MMR booster based on the current recommendations and guidelines by the Center for Disease Control (CDC)?

• A. 13 to 18 years of age.
• B. 11 to 12 years of age.
• C. 18 to 24 months of age.
• D. 4 to 6 years of age.

Correct answer: D

Rationale: The correct answer is D: 4 to 6 years of age. The CDC recommends the MMR booster for children in this age group. Choice A (13 to 18 years of age) is incorrect as it is not the recommended age range for the MMR booster. Choice B (11 to 12 years of age) is also incorrect as it does not align with the CDC guidelines for the MMR booster. Choice C (18 to 24 months of age) is not the correct age range for the MMR booster according to CDC recommendations.

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