Nursing Elites

1. Which of the following is designed to help clients reduce the risk of illness and maintain the maximum level of function?

• A. illness prevention
• B. crisis intervention
• C. rehabilitation
• D. health promotion

Correct answer: D

Rationale: The correct answer is 'D: health promotion.' Health promotion strategies are aimed at helping individuals reduce the risk of illness and maintain their maximum level of function by emphasizing preventive measures, healthy behaviors, and lifestyle choices. Illness prevention (choice A) focuses on specific actions to avoid illness but may not necessarily address overall function. Crisis intervention (choice B) refers to immediate assistance during emergencies rather than long-term prevention. Rehabilitation (choice C) involves restoring function after illness or injury rather than primarily focusing on preventive measures and maintaining maximum function.

2. To individualize care for a client and ensure maximum participation in that care, what should the nurse consider as the most important factor in planning the said care?

• A. environment
• B. educational attainment
• C. health beliefs and practices
• D. health status

Correct answer: C

Rationale: The correct answer is C: health beliefs and practices. Health beliefs and practices directly influence a client's willingness and ability to participate in care. Understanding a client's health beliefs and practices helps the nurse tailor the care plan to align with the client's values and preferences. Choice A, environment, though important, may not be the most critical factor in individualizing care. Choice B, educational attainment, is relevant but not as significant as understanding the client's health beliefs and practices. Choice D, health status, is essential but does not address the individualization of care and maximizing participation as directly as health beliefs and practices.

3. The nurse is caring for a client with status epilepticus. The most important nursing assessment of this client is

• A. Intravenous fluid infusion
• B. Level of consciousness
• C. Pulse and respirations
• D. Extremities for injuries

Correct answer: B

Rationale: In status epilepticus, the most crucial nursing assessment is the level of consciousness. Assessing the client's level of consciousness is vital as prolonged seizures can result in hypoxia, brain damage, and require immediate intervention. Pulse and respirations (choice C) are important assessments, but in status epilepticus, the priority is to monitor the client's neurological status. Checking intravenous fluid infusion (choice A) and extremities for injuries (choice D) are not the primary assessments needed in managing a client experiencing status epilepticus.

4. A client with HIV/AIDS is receiving zidovudine (Retrovir). The nurse should monitor the client for which of the following adverse effects?

• A. Hyperglycemia
• B. Anemia
• C. Hypertension
• D. Hypercalcemia

Correct answer: B

Rationale: The correct answer is B: Anemia. Zidovudine (Retrovir) can cause bone marrow suppression, leading to anemia. Monitoring for signs of anemia, such as fatigue, pallor, and shortness of breath, is crucial. Choice A, Hyperglycemia, is not a common adverse effect of zidovudine. Choice C, Hypertension, is not directly associated with zidovudine use. Choice D, Hypercalcemia, is also not a typical adverse effect of zidovudine.

5. A client has developed thrombophlebitis of the left leg. Which nursing intervention should be given the highest priority?

• A. Elevate leg on 2 pillows
• B. Apply support stockings
• C. Apply warm compresses
• D. Maintain complete bed rest

Correct answer: A

Rationale: The highest priority nursing intervention for a client with thrombophlebitis of the left leg is to elevate the leg on 2 pillows. Elevating the leg helps reduce swelling and pain associated with thrombophlebitis by promoting venous return. Applying support stockings (choice B) can be beneficial but is not the highest priority as elevation is more effective in the acute phase. Applying warm compresses (choice C) may worsen the condition by dilating the blood vessels, leading to increased pain and swelling. Maintaining complete bed rest (choice D) is important, but elevation takes precedence to improve circulation and reduce the risk of complications.

Similar Questions