Nursing Elites

1. While administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take?

• A. Have the client hold their breath briefly and bear down.
• B. Clamp the enema tubing.
• C. Remind the client that cramping is common at this time.
• D. Raise the level of the enema fluid container.

Correct answer: C

Rationale: When a client reports abdominal cramping during a cleansing enema, it is important for the nurse to reassure the client that cramping is a common side effect. This reassurance helps the client understand that the cramping is normal and may subside once the enema is completed. Instructing the client to hold their breath and bear down (Choice A) is not appropriate and may cause discomfort. Clamping the enema tubing (Choice B) is unnecessary and could lead to complications. Raising the level of the enema fluid container (Choice D) does not address the client's discomfort due to cramping. Therefore, the most suitable action is to provide reassurance to the client about the common occurrence of cramping during the enema.

2. The healthcare provider is caring for a client with a suspected deep vein thrombosis (DVT). Which assessment finding should the healthcare provider report to the healthcare provider?

• A. Swelling and redness in the affected leg
• B. Pain in the affected leg
• C. Warmth and tenderness in the affected leg
• D. A positive Homans' sign

Correct answer: D

Rationale: A positive Homans' sign is a classic sign associated with deep vein thrombosis (DVT) and indicates the presence of a blood clot. This finding is crucial to report to the healthcare provider promptly for further evaluation and treatment. Swelling, redness, pain, warmth, and tenderness in the affected leg are common signs of DVT, but a positive Homans' sign specifically points towards a potential blood clot, making it the priority finding to be reported. Reporting other symptoms may also be important, but a positive Homans' sign is more specific to DVT and requires immediate attention.

3. Which of the following manifestations confirms the presence of pediculosis capitis in students?

• A. Scratching the head more than usual
• B. Flakes evident on a student's shoulders
• C. Oval pattern occipital hair loss
• D. Whitish oval specks sticking to the hair

Correct answer: D

Rationale: The correct answer is D. Whitish oval specks sticking to the hair shaft are nits, which are a definitive sign of pediculosis capitis (head lice). A: Scratching the head more than usual is a common symptom but not confirmatory of head lice infestation. B: Flakes evident on a student's shoulders may indicate dandruff or dry scalp, not necessarily head lice. C: Oval pattern occipital hair loss is not a typical manifestation of pediculosis capitis.

4. An assistive personnel says to the nurse, “This client is incontinent of stool three or four times a day. I get angry, and I think that the client is doing it just to get attention. I think we should put adult diapers on her.” Which is the appropriate nursing response?

• A. You should report this to the supervisor
• B. It is very upsetting to see an adult client regress
• C. Diapers are the best solution
• D. The client’s condition is not your concern

Correct answer: B

Rationale: The correct response is 'It is very upsetting to see an adult client regress.' In this situation, the nurse should acknowledge the emotional impact of caregiving on the assistive personnel and address it professionally. Choice A is incorrect because reporting to the supervisor may not directly address the emotional concerns raised. Choice C is incorrect because immediately resorting to diapers without further assessment or intervention is not the most appropriate solution. Choice D is incorrect as the client's well-being and care are a shared responsibility among healthcare team members.

5. A client with a history of hypertension is prescribed a beta-blocker. Which side effect should the LPN/LVN monitor for in this client?

• A. Increased appetite
• B. Dry mouth
• C. Bradycardia
• D. Insomnia

Correct answer: C

Rationale: The correct side effect that the LPN/LVN should monitor for in a client prescribed a beta-blocker is bradycardia. Beta-blockers work by slowing down the heart rate, which can lead to bradycardia as a common side effect. Monitoring the client's heart rate is crucial, as bradycardia can be a serious condition. Choices A, B, and D are incorrect because increased appetite, dry mouth, and insomnia are not typically associated with beta-blockers. Increased appetite is more commonly linked to certain medications like corticosteroids, dry mouth can be a side effect of anticholinergic medications, and insomnia may be a side effect of stimulant medications.

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