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 has right-sided paralysis following a cerebrovascular accident. Which of the following prescriptions should the nurse anticipate to prevent a plantar flexion contracture of the affected extremity?

• A. Ankle-foot orthotic
• B. Continuous passive motion machine
• C. Abduction splint
• D. Sequential compression device

Correct answer: A

Rationale: An ankle-foot orthotic is the correct choice to prevent a plantar flexion contracture in a paralyzed limb. An ankle-foot orthotic helps maintain proper alignment of the foot and ankle, preventing the foot from being permanently fixed in a pointed-down position. Continuous passive motion machines are typically used to promote joint movement after surgery and would not address the prevention of contractures in this case. Abduction splints are used to keep the legs apart and would not address the specific issue described. Sequential compression devices are used to prevent deep vein thrombosis by promoting circulation in the lower extremities and are not indicated for preventing plantar flexion contractures.

3. A client appears upset about the IV catheter insertion but does not communicate it to the nurse after being informed about the prescribed IV fluids. Which of the following is an appropriate nursing response?

• A. Ignore the client’s discomfort
• B. Reassure the client without addressing concerns
• C. Is there something about this procedure that concerns you?
• D. Proceed with the procedure

Correct answer: C

Rationale: The appropriate nursing response in this situation is to ask the client if there are any concerns about the procedure. By doing so, the nurse acknowledges the client's distress and opens up a dialogue to address any anxieties or misconceptions. Option A is incorrect as ignoring the client’s discomfort can lead to increased anxiety and potential harm. Option B is not ideal as reassuring the client without addressing specific concerns may not alleviate the client's distress. Option D is incorrect because proceeding with the procedure without addressing the client's unspoken concerns can further escalate the client's distress.

4. While documenting in a client’s medical record, which of the following entries should the nurse record?

• A. “Incision without redness or drainage”
• B. “Drank adequate amounts of fluid with meals”
• C. “Administered pain medication”
• D. “Oral temperature slightly elevated at 0800”

Correct answer: D

Rationale: The correct answer is D because documenting specific observations, such as an oral temperature being slightly elevated at a specific time, is crucial for monitoring the client's health status accurately. This type of information helps in assessing trends and changes in the client's condition over time. Choice A is incorrect as it lacks specificity and does not provide measurable data about the client's condition. Choice B is incorrect because it is a general statement related to client behavior rather than a specific health observation. Choice C is incorrect as it reflects an action taken by the nurse and not a direct client's condition or observation.

5. A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document?

• A. Pericardial friction rub
• B. Mitral stenosis
• C. Aortic regurgitation
• D. Tricuspid stenosis

Correct answer: B

Rationale: The correct answer is B: Mitral stenosis. A high-pitched scratching sound heard during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border indicates mitral stenosis, not a pericardial friction rub. Pericardial friction rub is a to-and-fro, grating, or scratching sound due to inflamed pericardial surfaces rubbing together, typically heard in early diastole and late systole. Aortic regurgitation and tricuspid stenosis would present with different auscultatory findings compared to the described scenario, making them incorrect choices in this context.

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