Nursing Elites

1. What intervention should be taken to minimize the risk for injury in a client with dementia?

• A. Use a bed exit alarm system.
• B. Place the client in restraints for safety.
• C. Ensure the client has frequent visitors to reduce isolation.
• D. Keep the client's room dark and quiet at night.

Correct answer: A

Rationale: The correct intervention to minimize the risk for injury in a client with dementia is to use a bed exit alarm system. Bed exit alarms are effective tools to alert healthcare providers when a client attempts to get out of bed, helping prevent falls and injuries. Placing the client in restraints (Choice B) is not the preferred method as it can lead to physical and psychological harm, restrict mobility, and increase agitation. While social interaction is important for clients with dementia, ensuring frequent visitors (Choice C) is not directly related to preventing physical injuries. Keeping the client's room dark and quiet at night (Choice D) may be soothing for some clients but does not directly address the risk for injury associated with dementia.

2. The nurse admits a 7 year-old to the emergency room after a leg injury. The x-rays show a femur fracture near the epiphysis. The parents ask what will be the outcome of this injury. The appropriate response by the nurse should be which of these statements?

• A. The injury is expected to heal quickly because of thin periosteum.
• B. In some instances the result is a retarded bone growth.
• C. Bone growth is stimulated in the affected leg.
• D. This type of injury shows more rapid union than that of younger children.

Correct answer: B

Rationale: A fracture near the epiphysis can result in retarded bone growth, so this should be communicated to the parents.

3. A nurse is counseling an older adult who describes having difficulty with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority?

• A. “I spent my whole life dreaming about retirement, and now I wish I had my job back.”
• B. “It’s been so stressful for me to have to depend on my child to help around the house.”
• C. “I just heard my friend Al die. That’s the third one in 3 months.”
• D. “I keep forgetting which medications I have taken during the day.”

Correct answer: C

Rationale: The correct answer is C. The statement expressing the loss of friends is the priority issue as it indicates potential grief and emotional distress. Losing multiple friends within a short period can have a profound impact on an older adult's emotional well-being. Option A expresses regret but does not indicate an immediate emotional crisis. Option B focuses on stress related to dependence, which is important but not as urgent as coping with loss. Option D highlights a memory concern, which is significant but does not address the emotional impact of loss.

4. A client with a history of peptic ulcer disease is admitted with abdominal pain. Which finding should the LPN/LVN report to the healthcare provider immediately?

• A. Positive bowel sounds
• B. Rebound tenderness
• C. Increased appetite
• D. Elevated temperature

Correct answer: D

Rationale: Elevated temperature is the correct finding to report immediately in a client with a history of peptic ulcer disease and abdominal pain. This could indicate a perforation or worsening of the condition, requiring prompt medical attention. Positive bowel sounds (Choice A) are a normal finding and not a cause for concern. Rebound tenderness (Choice B) is concerning but does not require immediate attention compared to an elevated temperature. Increased appetite (Choice C) is not a red flag symptom for peptic ulcer disease and can be considered a positive sign, not requiring immediate attention.

5. A nurse is talking with caregivers of a 12-year-old child. Which of the following issues verbalized by the caregivers should the nurse identify as the priority?

• A. “We just don’t understand why our child can’t keep up with the other kids in simple activities like running and jumping.”
• B. “Our child keeps trying to find ways around our household rules. They always want to make deals with us.”
• C. “We think our child is trying too hard to excel in math just to get the top grades in the class.”
• D. “Our child likes to sing and worries it will make the other kids want to laugh.”

Correct answer: A

Rationale: The correct answer is A. Difficulty in keeping up with physical activities like running and jumping may indicate an underlying physical or developmental issue that requires prompt assessment. This could be related to musculoskeletal problems, coordination difficulties, or other health concerns that need further evaluation. Choices B, C, and D, while important, do not address a potential physical or developmental issue that could impact the child's overall well-being. Addressing the child's physical limitations should be the priority to ensure appropriate support and intervention.

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