Nursing Elites

1. A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit, and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess?

• A. Bounding pulse
• B. Decreased blood pressure
• C. Dry mucous membranes
• D. Weak pulse

Correct answer: A

Rationale: A bounding pulse is indicative of fluid volume excess. In this case, the client's weight gain and edematous ankles already suggest fluid volume overload. A bounding pulse occurs due to increased blood volume and pressure. Choices B, C, and D are not indicative of fluid volume excess. Decreased blood pressure, dry mucous membranes, and weak pulse are more commonly associated with conditions such as dehydration or hypovolemia, where there is a decrease in fluid volume rather than an excess.

2. A healthcare professional working in the emergency department is witnessing the signing of informed consent forms for the treatment of multiple clients during their shift. Which of the following signatures may the healthcare professional legally witness?

• A. A 16-year-old client who is married
• B. A 27-year-old who has schizophrenia
• C. An adoptive parent who brings in their 8-year-old child
• D. A 17-year-old mother who brings in her toddler

Correct answer: A

Rationale: The correct answer is A. A 16-year-old who is married can legally sign an informed consent form. In this case, being married at 16 may indicate legal emancipation or the ability to consent to medical treatment. Choice B is incorrect because having schizophrenia doesn't automatically imply incapacity to provide informed consent. Choice C is incorrect as an adoptive parent does not have the legal authority to provide consent for medical treatment on behalf of a child without proper documentation. Choice D is incorrect as a 17-year-old mother would generally not have the legal capacity to give consent for her toddler, as parental consent is usually required for minors.

3. During an admission assessment of an older adult client, a nurse should identify which of the following findings as a potential indication of abuse?

• A. Bruises on the arms in various stages of healing
• B. Recent weight gain
• C. Complaints of joint pain
• D. Frequent visits to different providers

Correct answer: A

Rationale: Bruises on the arms in various stages of healing should be identified as a potential indication of abuse in an older adult. These bruises may suggest physical harm or neglect, which are concerning signs of abuse. Recent weight gain (Choice B) is not typically associated with abuse and can have various causes, such as dietary changes or health conditions. Complaints of joint pain (Choice C) are more likely related to musculoskeletal issues rather than abuse. Frequent visits to different providers (Choice D) could indicate seeking multiple opinions or healthcare needs and do not necessarily point to abuse.

4. A patient with stomatitis is receiving oral care education from a nurse. Which instructions will the nurse provide?

• A. Avoid commercial mouthwashes.
• B. Avoid normal saline rinses.
• C. Brush with a hard toothbrush.
• D. Brush with an alcohol-based toothpaste.

Correct answer: A

Rationale: The correct instruction for a patient with stomatitis is to avoid commercial mouthwashes. Commercial mouthwashes often contain alcohol and other ingredients that can irritate the already inflamed oral mucosa in patients with stomatitis. Avoiding commercial mouthwashes helps prevent further irritation and discomfort. Choice B is incorrect because normal saline rinses are gentle and can help soothe the oral mucosa in patients with stomatitis. Choice C is incorrect because a soft toothbrush should be used to prevent further irritation or injury to the gums. Choice D is incorrect because an alcohol-based toothpaste can be too harsh and drying for patients with stomatitis.

5. A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating?

• A. Fidelity
• B. Autonomy
• C. Beneficence
• D. Justice

Correct answer: A

Rationale: The correct answer is A: Fidelity. Fidelity in nursing ethics involves keeping promises and being faithful to commitments, demonstrating reliability and trustworthiness. In this scenario, the nurse is exemplifying fidelity by returning promptly to the client as promised. Choice B, Autonomy, refers to respecting a patient's right to make their own decisions, not relevant in this situation. Choice C, Beneficence, involves the duty to act in the best interest of the patient, which is not the primary focus here. Choice D, Justice, pertains to fairness and equity in the distribution of healthcare resources, not applicable to the nurse's actions in this case.

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