Nursing Elites

1. You are teaching a client about the patient-controlled analgesia (PCA) planned for post-operative care. Which statement indicates further teaching may be needed by the client?

• A. ''I will be receiving continuous doses of medication.''
• B. ''I should call the nurse before I take additional doses.''
• C. ''I will call for assistance if my pain is not relieved.''
• D. ''The machine will prevent an overdose.''

Correct answer: B

Rationale: PCA allows patients to self-administer pain medication within prescribed limits, without the need to call the nurse before taking an additional dose. Choice B suggests a misunderstanding of how PCA works, as the patient should be educated that they can self-administer doses within the safety parameters set by the healthcare provider. Choices A, C, and D demonstrate proper understanding of PCA, hence are not indicative of needing further teaching.

2. While explaining an illness to a 10-year-old, what should the nurse keep in mind about the cognitive development at this age?

• A. They are able to make simple associations of ideas
• B. They are able to think logically in organizing facts
• C. Interpretation of events originates from their own perspective
• D. Conclusions are based on previous experiences

Correct answer: B

Rationale: Correct answer: At the age of 10, children are in the stage of concrete operational thought, where they can think logically and organize facts. Choice A is incorrect as simple associations of ideas are more characteristic of earlier developmental stages. Choice C is incorrect as while children at this age are developing perspective-taking skills, their interpretations are not solely limited to their own perspective. Choice D is incorrect as while previous experiences influence their thinking, the ability to think logically and organize facts is more prominent in this stage of cognitive development.

3. A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to:

• A. A social worker from the local hospital
• B. An occupational therapist from the community center
• C. A physical therapist from the rehabilitation agency
• D. Another client with diabetes mellitus who takes insulin

Correct answer: B

Rationale: An occupational therapist is the most appropriate professional to refer the client to in this situation. Occupational therapists can provide assistance with techniques and tools to help the client manage insulin administration despite arthritis. Referring the client to a social worker (Choice A) may not directly address the client's difficulty with insulin. While physical therapists (Choice C) focus on mobility and strength, they may not specialize in techniques for insulin administration. Referring the client to another client with diabetes (Choice D) is not a professional or appropriate solution to address the client's difficulty.

4. 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.

5. What components should a nurse include when conducting a community health assessment?

• A. Personal health history of community members
• B. Number of hospitals in the community
• C. Demographic data, health status indicators, and community resources
• D. Results of laboratory tests

Correct answer: C

Rationale: When conducting a community health assessment, it is essential to gather demographic data (such as age, gender, ethnicity), health status indicators (like prevalence of diseases, mortality rates), and information on community resources (such as healthcare facilities, social services). These components help in understanding the health needs of the community and planning appropriate interventions. Choices A, B, and D are not typically part of a community health assessment as they focus on individual health data or specific medical information rather than the broader population health perspective required for community assessments.

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