Nursing Elites

1. A client is complaining of difficulty walking secondary to a mass in the foot. The nurse should document this finding as:

• A. Plantar fasciitis.
• B. Hallux valgus.
• C. Hammertoe.
• D. Morton's neuroma.

Correct answer: D

Rationale: The correct answer is Morton's neuroma. Morton's neuroma is a small mass or tumor in a digital nerve of the foot, causing pain and difficulty walking. Hallux valgus is commonly known as a bunion, involving a bony bump at the base of the big toe. Hammertoe is a condition where one toe is bent abnormally at the middle joint, resembling a hammer. Plantar fasciitis is characterized by pain and inflammation in the arch of the foot, not by a mass causing difficulty walking. Therefore, options A, B, and C are incorrect as they do not describe a mass in the foot leading to difficulty walking, unlike Morton's neuroma.

2. A month after receiving a blood transfusion, an immunocompromised client develops fever, liver abnormalities, a rash, and diarrhea. The nurse should suspect this client has:

• A. no relation to the blood transfusion.
• B. graft-versus-host disease (GVHD).
• C. myelosuppression.
• D. an allergic reaction to a recent medication.

Correct answer: B

Rationale: In this scenario, the symptoms of fever, liver abnormalities, rash, and diarrhea in an immunocompromised client a month after a blood transfusion are indicative of graft-versus-host disease (GVHD). GVHD occurs when white blood cells in donor blood attack the tissues of an immunocompromised recipient. This process can manifest within a month of the transfusion. While choices 1 and 4 are plausible, it is crucial for the nurse to consider the possibility of GVHD in immunocompromised transfusion recipients due to the significant risk. Myelosuppression, choice C, typically presents with decreased blood cell counts and is not consistent with the symptoms described. An allergic reaction to medication, choice D, would present with different manifestations such as itching, hives, or anaphylaxis, which are not described in the scenario.

3. Which of the following is not typically considered one of the main mechanisms of Type II Diabetes treatment?

• A. Medications
• B. Nutrition
• C. Increased activity
• D. Continuous Insulin

Correct answer: D

Rationale: Continuous Insulin is not typically considered one of the main mechanisms for treating Type II Diabetes. While medications, nutrition, and increased activity play crucial roles in managing Type II Diabetes, continuous insulin therapy is more common in Type I Diabetes or in specific cases of Type II Diabetes where other treatments are ineffective. Therefore, the correct answer is Continuous Insulin. Choices A, B, and C are mainstays in the treatment of Type II Diabetes, making them incorrect answers.

4. A nurse assesses an 83-year-old female's venous ulcer for the second time that is located near the right medial malleolus. The wound is exhibiting purulent drainage, and the patient has limited mobility in her home. Which of the following is the best course of action?

• A. Encourage warm water soaks to the right foot.
• B. Notify the case manager of the purulent drainage.
• C. Determine the patient's pulse in the right ankle.
• D. Recommend increased activity to reduce the purulent drainage.

Correct answer: A

Rationale: The correct course of action is to encourage warm water soaks to the right foot. This can help promote wound healing and alleviate discomfort. Before recommending increased activity or notifying additional team members, it is crucial to assess arterial blood flow by determining the patient's pulse in the right ankle. Poor arterial blood flow could worsen the condition, making increased activity inappropriate. While notifying the case manager of purulent drainage is important, addressing the wound care directly should be the primary focus at this stage.

5. What is the best position for a client immediately following a bilateral salpingooophorectomy?

• A. Fowler's
• B. Modified Sims
• C. Side lying
• D. Flat supine

Correct answer: C

Rationale: The best position for a client immediately following a bilateral salpingooophorectomy is side lying. This position promotes comfort with the knees flexed and ensures proper airway management. Fowler's position (Choice A) would not be ideal as it involves sitting at a 90-degree angle, potentially causing discomfort after this procedure. Modified Sims position (Choice B) is typically used for rectal examinations, not for post-surgical management. Flat supine (Choice D) may not be the best choice immediately after surgery as it does not provide the same level of comfort and airway protection as side lying with knees flexed.

Similar Questions