Nursing Elites

1. Which of the following statements does NOT apply to a nursing plan of care?

• A. It contains short-term goals
• B. It is developed by the patient's physician
• C. It must be continually evaluated
• D. It contains long-range goals

Correct answer: B

Rationale: The correct answer is B. A nursing plan of care is developed by the nursing staff, not the patient's physician. Choice A is correct as nursing plans of care typically include short-term goals to address immediate patient needs. Choice C is correct because nursing plans of care must be continually evaluated and adjusted based on the patient's progress. Choice D is incorrect as nursing plans of care can include both short-term and long-range goals to address the patient's overall health and well-being.

2. A 31-year-old client is seeking contraceptive information. Before responding to the client’s questions about contraceptives, the nurse obtains a health history. What factor in the client’s history indicates to the nurse that oral contraceptives are contraindicated?

• A. More than 30 years of age
• B. Had two multiple pregnancies
• C. Smokes 1 pack of cigarettes a day
• D. Has a history of borderline hypertension

Correct answer: C

Rationale: The correct answer is C. Smoking, especially in clients over 30, increases the risk of thromboembolic events, making oral contraceptives contraindicated. Choice A (More than 30 years of age) is not a direct contraindication for oral contraceptives. Choice B (Had two multiple pregnancies) is not a factor that contraindicates the use of oral contraceptives. Choice D (Has a history of borderline hypertension) is not a specific contraindication for oral contraceptives unless it is severe or uncontrolled hypertension.

3. The nurse is caring for a client whose religious background is Seventh Day Adventist (Church of GOD). Which nursing action(s) are most appropriate in terms of providing for the dietary needs of this client? Select all that apply.

• A. Providing snacks between meals
• B. Excluding caffeine and pork from the client's diet
• C. Removing coffee from the breakfast tray
• D. Ensuring that there is no pork on the dinner tray

Correct answer: B

Rationale: The correct answer is B. Seventh Day Adventists typically avoid caffeine and pork due to religious dietary restrictions. Providing snacks between meals (choice A) is not specifically related to the dietary needs of this client. While removing coffee from the breakfast tray (choice C) aligns with the client's dietary restrictions, ensuring no pork on the dinner tray (choice D) is redundant as it is already covered in the correct answer. Therefore, choices C and D are not necessary to include as separate options.

4. A client with a diagnosis of catatonic schizophrenia is expected to exhibit which clinical finding?

• A. Crying
• B. Self-mutilation
• C. Immobile posturing
• D. Repetitious activities

Correct answer: C

Rationale: In catatonic schizophrenia, immobile posturing is a common clinical finding where the patient may maintain a rigid or bizarre posture for prolonged periods. Crying (Choice A) is not typically associated with catatonic schizophrenia. Self-mutilation (Choice B) is more commonly seen in conditions like borderline personality disorder. Repetitious activities (Choice D) are not a hallmark symptom of catatonic schizophrenia.

5. The nurse is preparing a postoperative nursing care plan for the client recovering from a hemorrhoidectomy. Which intervention should the nurse implement?

• A. Establish a rapport with the client to decrease embarrassment when assessing the site
• B. Encourage the client to lie in the lithotomy position twice a day
• C. Milk the tube inserted during surgery to allow the passage of flatus
• D. Digitally dilate the rectal sphincter to express old blood

Correct answer: A

Rationale: Establishing rapport with the client is essential in postoperative care to create a trusting relationship, decrease embarrassment, and improve the client's comfort during assessments. Choice B is incorrect because the lithotomy position is not typically recommended post-hemorrhoidectomy. Choice C is incorrect because milking the tube inserted during surgery is not a standard practice after a hemorrhoidectomy. Choice D is incorrect as digitally dilating the rectal sphincter can cause harm and is not a part of routine post-hemorrhoidectomy care.

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