Nursing Elites

1. A client admitted with sudden onset of severe back pain of unknown origin. Which statement would be most effective for the nurse to use to elicit further information from this client about his pain?

• A. Tell me how you are feeling right now.
• B. Describe the pain you are experiencing.
• C. Can you tell me more about your back pain?
• D. When did the pain start and how severe is it?

Correct answer: B

Rationale: The correct answer is B: 'Describe the pain you are experiencing.' This question is the most effective as it prompts the client to provide detailed information about the nature of the pain, including its characteristics, intensity, and location. This detailed description can help the nurse in assessing the possible cause and severity of the pain. Choices A, C, and D are not as effective as they are either too general ('Tell me how you are feeling right now'), redundant ('Can you tell me more about your back pain?'), or focused only on timing and severity ('When did the pain start and how severe is it?').

2. The LPN/LVN is assisting with the care of a client who has had a stroke. Which intervention is most important to include in the client's plan of care to prevent joint contractures?

• A. Encourage the client to perform active range-of-motion exercises.
• B. Use pillows to keep the client's extremities in a functional position.
• C. Place the client in a prone position for 30 minutes each day.
• D. Perform passive range-of-motion exercises on the affected side.

Correct answer: B

Rationale: Using pillows to keep the client's extremities in a functional position is crucial in preventing joint contractures. This intervention helps maintain proper alignment of the joints and reduces the risk of contractures by preventing prolonged positioning that can lead to muscle shortening. Encouraging the client to perform active range-of-motion exercises (Choice A) is beneficial for maintaining mobility but may not be the most important intervention to prevent joint contractures. Placing the client in a prone position for 30 minutes each day (Choice C) can be helpful for preventing pressure ulcers but is not directly related to preventing joint contractures. Performing passive range-of-motion exercises on the affected side (Choice D) can aid in maintaining joint flexibility but may not be as crucial as using pillows to prevent joint contractures.

3. During a home safety assessment for a client receiving supplemental oxygen, which observation should the nurse identify as proper safety protocol?

• A. The client uses non-acetone nail polish remover.
• B. The client uses an electric razor for shaving.
• C. The client cleans their oxygen equipment weekly.
• D. The client uses wool blankets.

Correct answer: A

Rationale: The correct answer is A. Using non-acetone nail polish remover is crucial for clients on supplemental oxygen as acetone is flammable and poses a safety risk. Acetone can react with oxygen, increasing the fire hazard. Choices B, C, and D are incorrect. Electric razors can generate sparks, which are dangerous near oxygen due to the risk of ignition. While cleaning oxygen equipment is important, the type of nail polish remover used is more critical for immediate safety. Wool blankets can create static electricity, increasing the risk of fire around oxygen due to its flammability.

4. The caregiver is assessing an 8-month-old child with atonic cerebral palsy. Which statement from the caregiver supports the presence of this problem?

• A. When I place my finger in the left hand, the baby does not respond with a grasp.
• B. My baby does not seem to track objects when I move toys in front of their face.
• C. When it thundered loudly last night, the baby did not even startle.
• D. When I place the baby in a supine position, that's how I find the baby.

Correct answer: D

Rationale: The statement 'When I place the baby in a supine position, that's how I find the baby' supports the presence of atonic cerebral palsy. In this type of cerebral palsy, the child may have poor muscle tone, making it difficult for them to roll from a back-lying position. This inability to roll indicates a lack of muscle tone, which is a characteristic feature of atonic cerebral palsy. Choices A, B, and C do not directly relate to the muscle tone issues typical of atonic cerebral palsy. Choice A focuses on a lack of grasp response, which may suggest motor issues but not specifically atonic cerebral palsy. Choice B refers to visual tracking, and choice C is about the startle reflex, neither of which are defining characteristics of atonic cerebral palsy.

5. A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?

• A. Protective environment
• B. Airborne precautions
• C. Droplet precautions
• D. Contact precautions

Correct answer: D

Rationale: The correct answer is D: Contact precautions. When a client has an abdominal wound with purulent drainage, contact precautions are necessary to prevent the spread of infection through direct contact. Protective environment precautions are used for immunocompromised clients, airborne precautions are for diseases transmitted by airborne particles, and droplet precautions are for diseases transmitted by respiratory droplets. In this case, the focus is on preventing direct contact transmission, making contact precautions the most appropriate choice. Protective environment, airborne, and droplet precautions are not indicated in this scenario because the primary concern is the direct contact transmission of pathogens through the wound drainage.

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