Nursing Elites

1. A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention?

• A. Screening groups of older adults in nursing care facilities for early influenza manifestations
• B. Promoting hand hygiene to prevent the spread of influenza
• C. Administering influenza vaccinations
• D. Educating about the importance of healthy lifestyle choices to prevent influenza

Correct answer: A

Rationale: The correct answer is A. Secondary prevention aims to detect and address health issues early. Screening older adults in nursing care facilities for early influenza manifestations is an example of secondary prevention by identifying cases at an early stage. Choice B, promoting hand hygiene, is a form of primary prevention that aims to prevent the occurrence of influenza. Choice C, administering influenza vaccinations, is a form of primary prevention as well, focusing on preventing the disease before it occurs. Choice D, educating about healthy lifestyle choices, is more related to health promotion and primary prevention rather than secondary prevention.

2. A client had a mastectomy 6 months ago and expresses a decreased desire for sexual relations, stating “My body is so different now.” Which of the following responses should the nurse make?

• A. “Really, you look just fine to me. There’s no need to feel undesirable.”
• B. “I’m interested in finding out more about how your body feels to you.”
• C. “Consider an afternoon at a spa; a facial will make you feel more attractive.”
• D. “It’s still too soon to expect to feel normal. Give it a little more time.”

Correct answer: B

Rationale: In this situation, the appropriate response is to reflect on the client’s feelings and explore their experience. Choice A may unintentionally dismiss the client's concerns by not addressing their emotional needs. Choice C suggests a spa treatment as a solution without addressing the underlying emotional issues. Choice D implies that the client's feelings will resolve with time, which may not be helpful in addressing the client's current emotional state.

3. A home health nurse is teaching a new caregiver how to care for a client who has had a tracheostomy for 1 year. Which of the following instructions should the nurse include?

• A. Use tracheostomy covers when going outdoors.
• B. Maintain sterile technique when performing tracheostomy care.
• C. Do not remove the outer cannula for routine cleaning.
• D. Clean around the stoma with normal saline.

Correct answer: A

Rationale: The correct answer is to use tracheostomy covers when going outdoors. This instruction is important as it helps protect the airway from dust and other particles, reducing the risk of infection or irritation. Choice B is incorrect because maintaining sterile technique is crucial during tracheostomy care to prevent infections, but it is not the most pertinent instruction in this scenario. Choice C is incorrect as removing the outer cannula is not a routine cleaning procedure and should only be done by healthcare professionals when necessary. Choice D is incorrect because cleaning around the stoma with normal saline is not recommended as it can cause irritation to the skin and stoma site.

4. A nurse is planning an education session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client?

• A. Allow extra time for the client to respond to questions
• B. Expect the client to have difficulty understanding the information
• C. Avoid references to the client’s past experiences
• D. Keep the learning session private and one-on-one

Correct answer: A

Rationale: Corrected Choice A, allowing extra time for the client to respond to questions, is the appropriate strategy when educating an older adult with type 2 diabetes mellitus. Older adults may need additional time to process information and formulate responses. Choice B is incorrect as it assumes the client will have difficulty understanding the information, which may not be the case. Choice C is incorrect because referencing the client's past experiences can help personalize the education session. Choice D is also incorrect as keeping the learning session private and one-on-one may not be necessary for all clients and may limit the potential benefits of group education and support.

5. A nurse on a medical-surgical unit is caring for a group of clients. For which of the following clients should the nurse expect a prescription for fluid restriction?

• A. A client who has a new diagnosis of adrenal insufficiency
• B. A client who has heart failure
• C. A client who is receiving treatment for diabetic ketoacidosis
• D. A client who has abdominal ascites

Correct answer: B

Rationale: The correct answer is B. Fluid restriction is commonly prescribed for clients with heart failure to prevent fluid overload and exacerbation of heart failure symptoms. Heart failure often leads to fluid retention, and restricting fluid intake can help manage this condition. Adrenal insufficiency, diabetic ketoacidosis, and abdominal ascites do not typically require fluid restriction as a primary intervention. Adrenal insufficiency may require hormone replacement therapy, diabetic ketoacidosis requires fluid and electrolyte replacement, and abdominal ascites may require diuretics or paracentesis to remove excess fluid.

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