Nursing Elites

1. A female client asks a nurse about the advantages of using a female condom. The nurse discusses which advantage with the client?

• A. That it offers protection against sexually transmitted infections (STIs)
• B. That it cannot be used along with a male condom
• C. That it does not have to be discarded after use and can be used several times before a new one must be obtained
• D. That it is 100% effective in preventing pregnancy

Correct answer: A

Rationale: The correct answer is that the female condom offers protection against sexually transmitted infections (STIs). Unlike the male condom, the female condom is a loose-fitting tubular polyurethane pouch that is anchored over the labia and cervix. It is used once and then discarded, making choice C incorrect. Female and male condoms should not be used together, so choice B is incorrect. Additionally, no contraceptive method is 100% effective in preventing pregnancy, making choice D incorrect.

2. A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the client's blood. On the basis of this finding, the nurse makes which determination?

• A. Hepatitis immune globulin and vaccine will be administered to the newborn infant soon after birth
• B. The results are negative.
• C. The results indicate that the mother does not have hepatitis B
• D. The client needs to receive the hepatitis B series of vaccines.

Correct answer: A

Rationale: A hepatitis B screen is performed to identify antigens in maternal blood. If antigens are present, it indicates that the mother is a carrier, and the newborn will need to receive hepatitis immune globulin and vaccine soon after birth to prevent transmission. Therefore, choice A is correct. Choices B and C are incorrect because the presence of antigens indicates a positive result, not a negative one or the absence of hepatitis B in the mother. Choice D is incorrect as it suggests the client needs to receive the hepatitis B series of vaccines, which is not the immediate action required when antigens are found in the maternal blood.

3. When evaluating a kinetic family drawing, which of the following actions is most effective?

• A. asking the child to draw their family doing something
• B. offering specific suggestions of what to include in the drawing
• C. discouraging the child from talking about the drawing
• D. noting the omission of any family members

Correct answer: D

Rationale: When evaluating a kinetic family drawing, noting the omission of any family members is an effective action. It is crucial to observe and analyze all aspects of the drawing, including what is missing. This can provide valuable insights into the child's perception and relationships within the family. Asking the child to draw their family doing something (Choice A) is more related to initial instruction rather than evaluation. Offering specific suggestions (Choice B) can influence the child's drawing and should be avoided to maintain the authenticity of the representation. Discouraging the child from talking about the drawing (Choice C) is counterproductive as verbal expression can provide additional context and understanding.

4. The nurse is caring for a client who has dysphagia related to a stroke. The nurse works with the client to explain what food and beverages might minimize aspiration. What is this an example of?

• A. Health promotion
• B. Secondary prevention
• C. Tertiary prevention
• D. Primary prevention

Correct answer: B

Rationale: The nurse working with the client to explain what food and beverages might minimize aspiration is an example of secondary prevention. Secondary prevention involves early detection and intervention to prevent complications or worsening of a condition. In this case, the nurse is helping to prevent aspiration pneumonia by providing education and guidance on safe eating and drinking practices after the client has already experienced dysphagia due to a stroke. Choice A, health promotion, focuses on empowering individuals to adopt healthy behaviors to improve overall well-being and prevent illness. It is more about promoting general health rather than specific interventions related to a particular condition like dysphagia. Choice C, tertiary prevention, involves managing and rehabilitating a condition to prevent further complications or disabilities. In this scenario, the nurse is not yet addressing complications but rather actively preventing them. Choice D, primary prevention, aims to prevent the onset of a disease or condition before it occurs. The client in this case already has dysphagia, so the focus is on preventing further complications, making it a secondary prevention intervention.

5. A nurse is participating in a planning conference to improve dietary measures for an older client experiencing dysphagia. Which action should the nurse suggest including in the plan of care?

• A. Monitoring the client during meals to ensure that food is swallowed
• B. Encouraging the client to feed themselves
• C. Consulting with the physician regarding feeding through an enteral tube
• D. Ensuring that the diet consists of both solids and liquids

Correct answer: A

Rationale: For clients with dysphagia, ensuring successful swallowing of food and preventing aspiration is crucial. Therefore, the nurse should suggest monitoring the client closely during meals to provide assistance as needed. While a balanced diet is important, special considerations like adding thickeners for liquids may be required for dysphagia clients. Consulting with a physician about enteral tube feeding should be based on the severity of the condition, making it a premature step without clear indications. Encouraging self-feeding may not be appropriate for dysphagia clients who require close monitoring and assistance, as it could increase the risk of complications.

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