Nursing Elites

1. A client can receive the mumps, measles, rubella (MMR) vaccine if he or she:

• A. is pregnant.
• B. is immunocompromised.
• C. is allergic to neomycin.
• D. has a cold.

Correct answer: D

Rationale: A client can receive the MMR vaccine if he or she has a cold. A simple cold without fever does not preclude vaccination. Pregnant women and immunocompromised individuals cannot receive the MMR vaccine due to the live rubella component, which may lead to birth defects or disease. Choice C is incorrect because individuals with anaphylactic reactions to neomycin should not receive the measles vaccine according to the American Academy of Pediatrics.

2. Which laboratory test would be the least effective in diagnosing a myocardial infarction?

• A. AST
• B. Troponin
• C. CK-MB
• D. Myoglobin

Correct answer: A

Rationale: AST, choice A, would be the least effective in diagnosing a myocardial infarction as it is not specific for this condition. Troponin, CK-MB, and myoglobin (choices B, C, and D) are more specific markers for myocardial infarction. Troponin is considered the gold standard due to its cardiac specificity. CK-MB is also specific to the heart, and its isoenzyme levels elevate post-heart damage. Myoglobin, although elevated in myocardial infarction, is not as specific as troponin and CK-MB and can also increase in conditions like burns and muscle trauma. Therefore, AST is the least effective choice for diagnosing a myocardial infarction.

3. During the history assessment of an 80-year-old client, which statement made by the client might indicate a possible fluid and electrolyte imbalance?

• A. "My skin is always so dry."?
• B. "I often use a laxative for constipation."?
• C. "I have always liked to drink a lot of iced tea."?
• D. "I sometimes have a problem with dribbling urine."?

Correct answer: B

Rationale: The correct answer is "I often use a laxative for constipation." Frequent use of laxatives can lead to diarrhea and electrolyte loss, indicating a possible fluid and electrolyte imbalance. Statements A, C, and D are not directly related to fluid and electrolyte imbalance. Statement A about dry skin may suggest dehydration, but it is less specific to electrolyte imbalance than the frequent use of laxatives. Statement C about drinking a lot of iced tea could potentially relate to fluid intake, but it doesn't directly indicate an imbalance. Statement D about dribbling urine is more indicative of a potential urinary issue rather than a fluid and electrolyte imbalance.

4. The nurse is caring for a client with cerebral palsy. The nurse should provide frequent rest periods because:

• A. Grimacing and writhing movements decrease with relaxation and rest.
• B. Hypoactive deep tendon reflexes become more active with rest.
• C. Stretch reflexes are increased with rest.
• D. Fine motor movements are improved.

Correct answer: A

Rationale: Frequent rest periods help to relax tense muscles and preserve energy in clients with cerebral palsy. This can lead to a decrease in grimacing and writhing movements, as relaxation and rest help to alleviate muscle tension. Choices B, C, and D are incorrect because they provide inaccurate information. Hypoactive deep tendon reflexes do not become more active with rest; stretch reflexes are not increased with rest in cerebral palsy patients, and fine motor movements are not necessarily improved solely by rest.

5. Which of the following roommates would be most suitable for the client with myasthenia gravis?

• A. A client with hypothyroidism
• B. A client with Crohn's disease
• C. A client with pyelonephritis
• D. A client with bronchitis

Correct answer: A

Rationale: The most suitable roommate for the client with myasthenia gravis is the client with hypothyroidism because they are quiet. A client with Crohn's disease (choice B) would be up to the bathroom frequently due to gastrointestinal issues, which could disturb the roommate with myasthenia gravis. A client with pyelonephritis (choice C) suffering from a kidney infection will need to urinate frequently, causing disturbances. A client with bronchitis (choice D) will be coughing, potentially disrupting the rest and quiet environment needed by a roommate with myasthenia gravis to manage their symptoms effectively.

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