Nursing Elites

1. To improve overall health, the nurse should place the highest priority on assisting a client to make lifestyle changes for which of the following habits?

• A. drinking a six-pack of beer each day
• B. eating an occasional chocolate bar
• C. exercising twice a week
• D. using relaxation exercises to deal with stress

Correct answer: A

Rationale: To improve overall health, the nurse should prioritize assisting the client in making lifestyle changes that have the most significant impact on health. Drinking a six-pack of beer each day can have serious negative effects on health, including liver damage, increased risk of chronic diseases, and addiction. By addressing this habit first, the nurse can make a substantial positive difference in the client's health. Eating an occasional chocolate bar, exercising twice a week, and using relaxation exercises to deal with stress are beneficial habits, but they are not as detrimental to health as excessive alcohol consumption. Therefore, they are not the highest priority for immediate lifestyle changes to improve health.

2. A client turns her ankle. She is diagnosed as having a Pulled Ligament. This should be documented as a:

• A. sprain.
• B. strain.
• C. subluxation.
• D. dislocation.

Correct answer: B

Rationale: The term 'strain' is the correct choice. A strain refers to the excessive stretching of a muscle or tendon, which aligns with a pulled ligament diagnosis. A sprain, on the other hand, involves ligament injury due to twisting motions. 'Subluxation' indicates a partial dislocation of a joint, not a pulled ligament. 'Dislocation' refers to the complete displacement of bones in a joint, which is not the appropriate term for a pulled ligament.

3. A woman who delivered a healthy newborn 6 hours earlier complains of discomfort at the episiotomy site. Which action by the nurse is the most appropriate?

• A. Administering an intravenous (IV) opioid analgesic
• B. Assisting the woman in taking a warm sitz bath
• C. Applying an ice pack to the perineum
• D. Contacting the registered nurse

Correct answer: C

Rationale: Applying an ice pack to the perineum is the most appropriate action in this scenario. Ice causes vasoconstriction, providing relief by numbing the area and preventing edema. It is typically used within the first 12 to 24 hours after birth. Assisting the woman in taking a warm sitz bath is more suitable after 24 hours as warm water can be soothing. Administering an IV opioid analgesic is excessive; an anesthetic spray is more appropriate for surface discomfort. Contacting the registered nurse is unnecessary as applying an ice pack is within the nurse's scope and can effectively address the discomfort without escalation.

4. To identify risk factors associated with the use of an oral contraceptive, which question should the nurse ask a client providing subjective data?

• A. Do you normally experience menstrual cramps with your periods?
• B. Do you smoke cigarettes?
• C. Are you currently dieting?
• D. Do you engage in strenuous exercise, such as jogging?

Correct answer: B

Rationale: The correct question the nurse should ask to identify risk factors associated with the use of an oral contraceptive is whether the client smokes cigarettes. Oral contraceptives are associated with an increased risk of thromboembolic phenomena, particularly when combined with other risk factors like smoking and a history of thrombosis. Other risk factors include hypertension, cerebrovascular disease, coronary artery disease, and postoperative thrombosis risk. Choices A, C, and D are not directly related to the increased risks associated with oral contraceptive use. Menstrual cramps, dieting, and strenuous exercise are not significant risk factors for thromboembolic events.

5. During data collection of a client with suspected carpal tunnel syndrome, a nurse plans to perform the Phalen test. The nurse should ask the client to perform which activity?

• A. Dorsiflex the foot
• B. Plantarflex the foot
• C. Hold the hands back to back while flexing the wrists 90 degrees for 60 seconds
• D. Hyperextend the fingers with the palmar surfaces of the hands touching, holding the position for 60 seconds

Correct answer: C

Rationale: In the Phalen test, the nurse asks the client to hold the hands back to back while flexing the wrists 90 degrees. This position puts pressure on the median nerve, eliciting symptoms in carpal tunnel syndrome. Dorsiflexing or plantarflexing the foot and hyperextending the fingers are not associated with testing for carpal tunnel syndrome. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand.

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