Nursing Elites

1. A 38-year-old patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care?

• A. Restrict daily dietary protein intake.
• B. Reposition the patient every 4 hours.
• C. Place the patient on a pressure-relieving mattress.
• D. Perform passive range of motion daily.

Correct answer: C

Rationale: Placing the patient on a pressure-relieving mattress is crucial to decrease the risk of skin breakdown, especially with significant edema and ascites. Adequate dietary protein intake is essential in patients with ascites to improve oncotic pressure and prevent malnutrition. Repositioning the patient every 4 hours alone may not be sufficient to prevent skin breakdown, especially in areas prone to pressure ulcers. Performing passive range of motion exercises is important for maintaining joint mobility but does not directly address the risk of skin breakdown associated with prolonged pressure on vulnerable areas.

2. The nurse is taking the health history of a patient being treated for Emphysema and Chronic Bronchitis. After being told the patient has been smoking cigarettes for 30 years, the nurse expects to note which assessment finding?

• A. Increase in Forced Vital Capacity (FVC)
• B. A widened chest cavity
• C. Clubbed fingers
• D. An increased risk of cardiac failure

Correct answer: C

Rationale: 1. Increase in Forced Vital Capacity (FVC): Forced Vital Capacity is the volume of air exhaled from full inhalation to full exhalation. A patient with COPD would have a decrease in FVC. Therefore, this choice is incorrect. 2. A widened chest cavity: A patient with COPD often presents with a 'barrel chest,' which is seen as a widened chest cavity. Hence, a narrowed chest cavity is not an expected finding. 3. Clubbed fingers - CORRECT: Clubbed fingers are a sign of a long-term, or chronic, decrease in oxygen levels, which is commonly seen in patients with chronic respiratory conditions like Emphysema and Chronic Bronchitis. 4. An increased risk of cardiac failure: Although a patient with these conditions would indeed be at an increased risk for cardiac failure, this is a potential complication and not an assessment finding, making it an incorrect choice.

3. When taking a patient’s history, she mentions being depressed and dealing with an anxiety disorder. Which of the following medications would the patient most likely be taking?

• A. Amitriptyline (Elavil)
• B. Calcitonin
• C. Pergolide mesylate (Permax)
• D. Verapamil (Calan)

Correct answer: A

Rationale: The correct answer is Amitriptyline (Elavil) as it is a tricyclic antidepressant commonly used to treat symptoms of depression and anxiety disorders. Amitriptyline works by increasing the levels of certain neurotransmitters in the brain to improve mood. Choices B, C, and D are incorrect. Calcitonin is a hormone used in the treatment of osteoporosis; Pergolide mesylate is a dopamine agonist used in Parkinson's disease; Verapamil is a calcium channel blocker used to treat high blood pressure and certain heart conditions, not mental health disorders.

4. A 3-year-old child is seen in the health care clinic, and a diagnosis of encopresis is made. The nurse expects to provide teaching about which client problem?

• A. Odor
• B. Nausea
• C. Malaise
• D. Diarrhea

Correct answer: A

Rationale: Encopresis is the repeated voluntary or involuntary passage of feces of normal or near-normal consistency in places not appropriate for that purpose according to the individual's own sociocultural setting. Signs of encopresis include evidence of soiled clothing, scratching or rubbing the anal area due to irritation, fecal odor without apparent awareness by the child, and social withdrawal. Teaching about odor is essential to address the issue of encopresis. Choices B, C, and D are incorrect because encopresis is not typically associated with nausea, malaise, or diarrhea. Therefore, teaching about these symptoms would not be relevant in the context of encopresis.

5. A client who has undergone radiation therapy presents with itching, redness, burning pain, and skin sloughing on the chest and abdomen. Which nursing intervention is most appropriate for this client?

• A. Apply ointment to the skin to avoid moisture
• B. Wash the area gently with water and pat dry
• C. Use a mild antiseptic soap to wash the area and pat dry
• D. Apply talcum powder to keep the skin dry

Correct answer: B

Rationale: For a client experiencing skin symptoms like redness, itching, burning pain, and sloughing after radiation therapy, it is crucial to maintain proper skin care. Applying ointments, lotions, or powders can worsen the condition by trapping moisture and leading to further skin irritation. The most appropriate intervention is to wash the affected area gently with water to cleanse it without further irritating the skin. Using mild antiseptic soap or talcum powder can also be harsh on the compromised skin. Patting the skin dry helps prevent friction and trauma to the affected area, promoting healing and comfort.

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