Nursing Elites

1. When assessing a client with sinusitis, which technique should the nurse use to identify manifestations of this disorder?

• A. Percussion of the frontal sinuses
• B. Auscultation of the trachea
• C. Inspection of the nasal mucosa
• D. Palpation of the orbital areas

Correct answer: D

Rationale: Sinusitis is an inflammation of the sinus cavities, which can cause tenderness and pain around the eyes (orbital areas). Palpation of the orbital areas can help identify tenderness and swelling associated with sinusitis. Auscultation of the trachea and percussion of the frontal sinuses are not relevant assessment techniques for sinusitis. Inspection of the nasal mucosa may reveal signs of inflammation, but palpation of the orbital areas is a more direct method to assess for tenderness and swelling in this specific condition.

2. What is the appropriate route of administration for insulin?

• A. Intramuscular
• B. Intradermal
• C. Subcutaneous
• D. Intravenous

Correct answer: C

Rationale: The appropriate route of administration for insulin is subcutaneous. Subcutaneous injections are commonly used for insulin administration due to the slower absorption rate compared to intramuscular or intravenous routes. This slower absorption rate allows for better control of blood glucose levels. Intramuscular administration is not ideal for insulin as it can lead to rapid absorption and fluctuations in blood sugar levels. Intradermal injections are shallow and used for skin testing rather than insulin administration. Intravenous administration of insulin is not recommended due to the rapid and unpredictable effects it can have on blood glucose levels.

3. A client is recovering from an acute myocardial infarction that occurred 3 days ago. Which of the following instructions should the nurse include in the care plan?

• A. Perform an ECG every 12 hours.
• B. Place the client in a supine position while resting.
• C. Draw a troponin level every 4 hours.
• D. Obtain a cardiac rehabilitation consultation.

Correct answer: D

Rationale: After an acute myocardial infarction, cardiac rehabilitation is crucial for the client's recovery. It helps improve the client's overall cardiovascular health, reduces the risk of future cardiac events, and promotes a healthy lifestyle. The other options do not directly address the importance of cardiac rehabilitation in the client's recovery process.

4. When discussing hair loss with Mrs. Lim, who begins to cry, the best response would be:

• A. Don’t worry. It’s only temporary
• B. Why are you crying? I didn’t get to the bad news yet
• C. Your hair is really pretty
• D. I know this will be difficult for you, but your hair will grow back after the completion of chemotherapy

Correct answer: D

Rationale: When a patient is emotionally affected, it is essential to acknowledge their feelings while providing reassurance and information. Option D demonstrates empathy by acknowledging the difficulty Mrs. Lim is facing and offers hope by reassuring her that her hair will grow back after chemotherapy, which can provide comfort and support during a challenging time.

5. When creating a plan of care for a newly admitted client with obsessive-compulsive disorder, which of the following interventions should the nurse take?

• A. Allow the client enough time to perform rituals
• B. Give the client autonomy in scheduling activities
• C. Discourage the client from exploring irrational fears
• D. Provide negative reinforcement for ritualistic behaviors

Correct answer: A

Rationale: Individuals with obsessive-compulsive disorder often feel compelled to perform rituals to alleviate anxiety. Allowing the client enough time to perform these rituals can help reduce their anxiety levels and promote a sense of control. Providing autonomy in scheduling activities can also empower the client and enhance their sense of independence. Discouraging exploration of irrational fears may increase anxiety and worsen symptoms. Negative reinforcement for ritualistic behaviors is not recommended as it can be counterproductive and reinforce the behavior.

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