Nursing Elites

1. Which risk factor places patients and residents at the greatest risk for falls?

• A. Old age
• B. Middle age
• C. Pneumonia
• D. COPD

Correct answer: A

Rationale: Old age is a significant risk factor for falls as elderly individuals are more prone to falls due to factors like decreased balance, muscle strength, and vision. Middle age is less associated with falls compared to old age. Pneumonia and COPD are medical conditions that are not direct risk factors for falls, unlike aging which significantly increases the risk of falls.

2. A new mother has some questions about phenylketonuria (PKU). Which of the following statements made by a nurse is not correct regarding PKU?

• A. A Guthrie test can check the necessary lab values.
• B. The urine has a high concentration of phenylpyruvic acid
• C. Mental deficits are often present with PKU
• D. The effects of PKU are reversible

Correct answer: D

Rationale: Phenylketonuria (PKU) is an inherited disorder that increases the levels of phenylalanine (a building block of proteins) in the blood. If PKU is not treated, phenylalanine can build up to harmful levels in the body, causing intellectual disability and other serious health problems. The signs and symptoms of PKU vary from mild to severe. The most severe form of this disorder is known as classic PKU. Infants with classic PKU appear normal until they are a few months old. Without treatment, these children develop a permanent intellectual disability. Seizures, delayed development, behavioral problems, and psychiatric disorders are also common. Untreated individuals may have a musty or mouse-like odor as a side effect of excess phenylalanine in the body. Children with classic PKU tend to have lighter skin and hair than unaffected family members and are also likely to have skin disorders such as eczema. The effects of PKU stay with the infant throughout their life (via Genetic Home Reference).

3. Which of the following is an example of a living will?

• A. A client's son has been appointed to make his healthcare decisions if he becomes incapacitated
• B. A client has designated which of his children will receive his home and property before he dies
• C. A client has instructions that he does not want to be resuscitated through chest compressions if his heart stops beating
• D. A client designates what type of burial or cremation services he would want after his death

Correct answer: C

Rationale: A living will is a type of advanced directive that a client develops to stipulate his preferences for healthcare in the event that he is unable to do so. This includes specific instructions about medical treatments in certain situations. Choice C is the correct answer as it reflects a scenario where the client has clearly outlined their preference regarding resuscitation through chest compressions. Choices A, B, and D do not pertain to a living will. Choice A involves a healthcare proxy or agent, choice B involves a will or estate planning, and choice D involves funeral or burial arrangements, which are not part of a living will.

4. Mr. Freeman has difficulty getting out of bed. The nurse should encourage Mr. Freeman to ______________.

• A. ask for assistance before getting out of bed.
• B. remain in bed because it is safer and he will not fall.
• C. instruct him to stand up quickly from the bed.
• D. lean forward and push up and off the bed.

Correct answer: A

Rationale: The nurse should encourage Mr. Freeman to use his call bell and ask for assistance before getting out of bed. This can prevent him from falling. Patients should not stay in bed; they should be encouraged to get out of bed as much as possible to prevent complications like pressure ulcers and muscle weakness. Instructing a patient to stand up quickly from the bed is unsafe as it can lead to dizziness and falls. Similarly, leaning forward and pushing off the bed can increase the risk of falls and should be avoided. Asking for assistance is the safest and most appropriate option to ensure patient safety and prevent accidents.

5. At the beginning of the shift, a nurse receives report for her daily assignment. Which of the following situations should the nurse give first priority?

• A. A diabetic client with a blood glucose level of 195 mg/dL
• B. A family member of an elderly client who has questions
• C. A client with COPD with an oxygen saturation of 84%
• D. A client who requires assistance to use the bathroom

Correct answer: C

Rationale: When prioritizing the needs of clients, the nurse must begin with the unstable client or manage conditions that affect airway, breathing, or circulation first. The client with COPD has a condition that affects breathing and is exhibiting decreased oxygen saturation levels; therefore, this client should be the first priority. Option A, the diabetic client with a blood glucose level of 195 mg/dL, does not present an immediate threat to airway, breathing, or circulation. Option B, addressing questions from a family member, is important but can be addressed after addressing critical patient needs. Option D, assisting a client to use the bathroom, is a routine task that can be prioritized after addressing urgent medical needs.

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