Nursing Elites

1. A client who had a hip replacement is being prepared for discharge. What should the nurse include in the discharge teaching to prevent hip dislocation?

• A. Avoid crossing your legs at the knees or ankles.
• B. Do not sleep on the side of the hip that was operated on.
• C. Sit in high chairs and keep your knees higher than your hips.
• D. Do not bend forward at the waist to pick up objects.

Correct answer: A

Rationale: The correct answer is A: 'Avoid crossing your legs at the knees or ankles.' Crossing legs at the knees or ankles can cause excessive stress on the new hip joint, leading to a risk of dislocation. Choice B is incorrect because sleeping on the side of the operated hip can also increase the risk of dislocation. Choice C is incorrect as sitting in low chairs with knees higher than hips is a recommended position to prevent hip dislocation. Choice D is incorrect because bending forward at the waist to pick up objects can strain the hip joint and increase the risk of dislocation.

2. The PN observes a UAP bathing a bedfast client with the bed in the high position. Which action should the PN take?

• A. Remain in the room to supervise the UAP
• B. Determine if the UAP would like assistance
• C. Assume care of the client immediately
• D. Instruct the UAP to lower the bed for safety

Correct answer: D

Rationale: The correct action for the PN to take in this situation is to instruct the UAP to lower the bed for safety. Keeping the bed in the lowest position during care activities is crucial for preventing falls and injuries to both the client and the caregiver. Instructing the UAP to lower the bed addresses the immediate safety concern. Choice A is incorrect because simply supervising the UAP without addressing the unsafe bed height does not ensure the client's safety. Choice B is incorrect as the priority is to address the safety concern rather than offering assistance to the UAP. Choice C is incorrect as assuming care of the client immediately does not address the root issue of the high bed position.

3. The PN is caring for a client with schizophrenia who continues to repeat the last words heard. Which nursing problem should the PN document in the medical record?

• A. Altered thought processes
• B. Impaired social interaction
• C. Risk for self-directed violence
• D. Disturbed thought processes

Correct answer: D

Rationale: The correct answer is D: Disturbed thought processes. Echolalia, the repetition of heard words, is associated with disturbed thought processes, which are commonly seen in schizophrenia. Altered thought processes (Choice A) is a generic term and does not specifically address the behavior of repeating words. Impaired social interaction (Choice B) is not the primary concern when a client repeats the last words heard. Risk for self-directed violence (Choice C) is not directly related to the behavior of repeating words but focuses on the potential harm the client may cause to themselves.

4. A Native American client is admitted with a diagnosis of psychosis not otherwise specified. The client's family seems to regard the client's hallucinations as normal. What assessment can be made?

• A. The client's family regards the hallucinations from a cultural context
• B. The client will benefit from a talking circle
• C. The client will need a medicine man
• D. The client will need a single room

Correct answer: A

Rationale: Choice A is correct because the family may interpret the client's hallucinations through their cultural lens, potentially viewing them as normal or spiritually significant. Understanding and acknowledging the cultural context is essential for providing culturally sensitive care. Choices B, C, and D are incorrect because while talking circles and seeking guidance from a medicine man may be culturally relevant interventions in some contexts, the priority in this situation is to recognize and respect the family's perspective on the client's hallucinations.

5. You have a patient who has just had a diagnostic arthroscopy. You are instructing him about what to do when he gets home. Which of the following would you NOT instruct him to do?

• A. Resume normal activities within 12 hours so as to help reduce the swelling
• B. Elevate the extremity for 24 – 48 hours
• C. Apply ice to the area involved intermittently
• D. Report severe pain to the physician immediately

Correct answer: A

Rationale: Patients should rest and avoid normal activities for a short period after arthroscopy to allow healing and prevent swelling, which could worsen with early activity. Elevation and icing are recommended post-procedure to reduce swelling and pain. Instructing the patient to resume normal activities within 12 hours could lead to increased swelling and delayed healing. Reporting severe pain is crucial as it could indicate a complication. Therefore, the correct instruction is not to resume normal activities immediately after arthroscopy.

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