Nursing Elites

1. Which of the following might be an appropriate nursing diagnosis for an epileptic client?

• A. Dysreflexia
• B. Risk for Injury
• C. Urinary Retention
• D. Unbalanced Nutrition

Correct answer: B

Rationale: The correct answer is 'Risk for Injury.' Epileptic clients are at risk for injury due to complications of seizure activity, such as falls that could lead to head trauma. 'Dysreflexia' is not typically associated with epilepsy but rather with spinal cord injury. 'Urinary Retention' is not a common nursing diagnosis for epileptic clients unless specifically indicated. 'Unbalanced Nutrition' may not be a priority nursing diagnosis compared to the immediate risk of injury in epileptic clients.

2. Pulling is easier than pushing. So pulling a client rather than pushing them has which of the following advantages?

• A. reduces workload
• B. decreases opposition from gravity
• C. maintains stability
• D. prevents muscle strain

Correct answer: A

Rationale: When pulling a client, you work with the gravitational force instead of opposing it, which reduces the workload on your muscles. Choosing to pull a client minimizes the effort required compared to pushing. Choice B is incorrect because the force of gravity remains constant regardless of pushing or pulling. Choice C is irrelevant as stability is not directly related to the advantage of pulling over pushing. Choice D is inaccurate because pulling can still strain muscles if not executed correctly, but it generally reduces the overall workload in comparison to pushing.

3. A 20-year-old male client had a diving accident with subsequent paraplegia. He says to the nurse, "No woman will ever want to marry me now."? Which of the following responses by the nurse is most therapeutic?

• A. "Don't worry. Maybe you'll meet a paraplegic woman."?
• B. "There is someone for everyone in this world."?
• C. "You are still an attractive man, even though you can't walk."?
• D. "Tell me more about your feelings on this issue."?

Correct answer: D

Rationale: The correct response is 'Tell me more about your feelings on this issue.' This answer is the most therapeutic as it encourages the client to express his emotions and concerns, fostering a supportive and open dialogue between the client and the nurse. Option A may come across as dismissive and does not directly address the client's emotional state. Option B, while positive, oversimplifies the client's complex feelings. Option C focuses only on physical appearance, missing the opportunity to delve deeper into the client's emotional well-being. Therefore, the most therapeutic response is to encourage further discussion about the client's feelings.

4. A client with cirrhosis of the liver presents with ascites. The physician is to perform a paracentesis. For safety, the nurse should ask the client to:

• A. drink 1000 cc of fluid prior to the procedure to aid in fluid loss.
• B. eat foods low in fat.
• C. empty his bladder prior to the procedure.
• D. assume the prone position.

Correct answer: C

Rationale: When performing a paracentesis, the client must be sitting up to allow the fluid to settle in the lower abdomen. To prevent trauma to the bladder while inserting a needle to aspirate the fluid, the bladder must be empty. Choice A is incorrect as excessive fluid intake can make the procedure more difficult due to increased abdominal distension. Choice B is unrelated to the procedure of paracentesis. Choice D is incorrect as the client should be sitting up, not in the prone position, during the procedure.

5. Which of the following adverse effects should the client on Floxin be alerted to?

• A. stunting of height in teens and young adults
• B. propensity for anovulatory uterine bleeding
• C. intractable diarrhea
• D. tendon rupture

Correct answer: D

Rationale: The correct answer is tendon rupture. Floxin is a quinolone antibiotic commonly used in respiratory infections and pelvic/reproductive infections. One of the rare adverse effects associated with quinolones is tendon sheath rupture, often affecting the Achilles tendon. Therefore, patients taking Floxin should be alerted to the possibility of tendon rupture. Choices A, B, and C are incorrect as they are not typically associated with Floxin use and are not common adverse effects of quinolone antibiotics. Stunting of height is not a recognized adverse effect of Floxin. Anovulatory uterine bleeding is not a known side effect of quinolones. Intractable diarrhea is not a common adverse effect of Floxin.

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