Nursing Elites

1. A client in the cardiac step-down unit requires suctioning for excess mucous secretions. The nurse should be most careful to monitor the client for which dysrhythmia during this procedure?

• A. Bradycardia
• B. Tachycardia
• C. Premature ventricular beats
• D. Heart block

Correct answer: A

Rationale: During suctioning, a vagal response can be triggered leading to bradycardia. It is crucial for the nurse to monitor for this potential dysrhythmia. Tachycardia (Choice B) is less likely during suctioning and is not the priority. Premature ventricular beats (Choice C) and heart block (Choice D) can occur but are less common compared to bradycardia in this situation.

2. The nurse is assessing an elder whom the nurse suspects is being physically abused. The most important question for the nurse to ask is:

• A. "How much money do you keep around the house?"?
• B. "Who provides your physical care?"?
• C. "How close does your nearest relative live?"?
• D. "What form of transportation do you use?"?

Correct answer: B

Rationale: The most important question for the nurse to ask when suspecting elder abuse is 'Who provides your physical care?' This question is crucial as the primary caregiver, who is often the abuser in cases of elder abuse, lives with the client. Research has shown that spouses and adult children are the most common abusers. By inquiring about the provider of physical care, the nurse can assess the potential abuser's proximity to the elder. Choices A, C, and D are less pertinent to identifying the primary caregiver, who is more likely to be the abuser.

3. The child with seizure disorder is being treated with Dilantin (phenytoin). Which of the following statements by the patient's mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy?

• A. "She is very irritable lately."?
• B. "She sleeps quite a bit of the time."?
• C. "Her gums look too big for her teeth."?
• D. "She has gained about 10 pounds in the last 6 months."?

Correct answer: C

Rationale: The correct answer is '"Her gums look too big for her teeth."?' Hyperplasia of the gums is a known side effect associated with Dilantin therapy. Option A, '"She is very irritable lately,"?' is not a typical side effect of Dilantin. Option B, '"She sleeps quite a bit of the time,"?' is a common side effect of Dilantin but not specific to gum hyperplasia. Option D, '"She has gained about 10 pounds in the last 6 months,"?' is not typically associated with Dilantin therapy and is unrelated to the question.

4. The nurse is assessing the client recently returned from surgery. The nurse is aware that the best way to assess pain is to:

• A. Take the blood pressure, pulse, and temperature
• B. Ask the client to rate his pain on a scale of 0-5
• C. Watch the client's facial expression
• D. Ask the client if he is in pain

Correct answer: B

Rationale: The best way to evaluate pain levels is to ask the client to rate his pain on a scale. This method provides a more standardized and quantifiable measure of pain compared to subjective observations like facial expressions (choice C) or direct questioning (choice D). Monitoring vital signs (choice A) can be part of pain assessment but is not as specific or reliable as asking the client to self-report pain intensity.

5. What is the primary goal of family education?

• A. symptom reduction
• B. improved quality of life
• C. increased knowledge about mental illness
• D. improved caregiving skills

Correct answer: B

Rationale: The primary goal of family education is to improve the quality of life. Family education aims to enhance the overall well-being and functioning of both the individual with the condition and their family members. While increased knowledge about mental illness may be a beneficial outcome, it is not the primary objective of family education. Symptom reduction is more commonly associated with psychoeducation rather than family education. Improving caregiving skills is a component of family education, but the primary focus is on improving the quality of life for everyone involved in the caregiving process.

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