Nursing Elites

1. A nurse assesses an audible grating sound (Crepitus) when a client with osteoarthritis moves his knees. What is the cause of this sound?

• A. A herniated disk in the diseased joint
• B. Pieces of bone and cartilage floating
• C. Popping bursae from standing
• D. Years of an autoimmune process

Correct answer: A

Rationale:

2. A client sustains an injury to his heel while the unlicensed assistive personnel and the nurse are moving him up in bed. What force caused the injury?

• A. Shearing or friction
• B. Twisting and bending
• C. Pressure or gravity
• D. Chemical or pressure

Correct answer: A

Rationale:

3. What is correct about a nursing diagnosis?

• A. It is a human response to disease, injury, or other stressors.
• B. It remains constant as long as the disease is present.
• C. It is a way to identify pathology.
• D. It is a disease, illness, or injury.

Correct answer: A

Rationale: A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems or life processes. Choice A is correct because it identifies nursing diagnosis as related to human responses to health conditions or life processes. Choice B is incorrect because nursing diagnoses can change as the patient's condition changes. Choice C is incorrect because a nursing diagnosis is about responses, not just identifying pathology. Choice D is incorrect because a nursing diagnosis is not the same as a disease, illness, or injury; it is a statement about the patient's response to these conditions.

4. An area of erythema on the child's skin is being assessed by the nurse. The nurse presses down on the area, and the area becomes white. What time does the nurse document for this finding?

• A. Non-blanching
• B. Blanching
• C. Redness
• D. Warmth

Correct answer: B

Rationale:

5. A client is bedridden and appears to be frail and malnourished. Which nursing interventions will increase the risk of pressure injury?

• A. Applying moisturizer to dry areas of the skin
• B. Massaging the client's reddened shoulders and heels
• C. Cleansing the skin routinely after soiling occurs
• D. Using a Hoyer lift for all transfers

Correct answer: B

Rationale:

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