Nursing Elites

1. During an assessment, a healthcare professional observes significant tenting of the skin over an older adult client's forearm. What factor should the healthcare professional primarily consider as a cause for this finding?

• A. Thin, parchment-like skin
• B. Loss of adipose tissue
• C. Dehydration
• D. Diminished skin elasticity

Correct answer: C

Rationale: Dehydration is the primary factor to consider in this scenario. Dehydration leads to decreased skin turgor and tenting, where the skin does not return to its normal position when pinched. While thin, parchment-like skin, loss of adipose tissue, and diminished skin elasticity can contribute to skin changes, they are not the primary cause of the significant tenting observed.

2. When should the nurse plan to collect a sputum specimen for culture and sensitivity as ordered by a client's provider?

• A. In the morning upon rising.
• B. Immediately after the client eats breakfast.
• C. Before the client goes to bed.
• D. After the client has had a drink of water.

Correct answer: A

Rationale: The correct time to collect a sputum specimen for culture and sensitivity is in the morning upon rising. This timing ensures the most concentrated sample as sputum produced overnight tends to accumulate and sit in the airways, providing a quality sample for testing. Collecting the specimen immediately after eating breakfast (choice B) may introduce food particles that could contaminate the sample. Collecting it before bed (choice C) may lead to a diluted sample due to daily activities. Collecting the specimen after having a drink of water (choice D) can also result in a diluted sample, impacting the accuracy of the test results.

3. A client in the terminal stage of cancer is crying. What action should the nurse take?

• A. Sit and hold the client's hand
• B. Encourage the client to talk about their feelings
• C. Leave the client alone to cry
• D. Ignore the client's crying

Correct answer: A

Rationale: In situations where a client is in the terminal stage of cancer and crying, it is essential for the nurse to provide comfort and support. Sitting with the client and holding their hand can offer a sense of presence and emotional support, showing empathy and understanding. Encouraging the client to talk about their feelings (choice B) is also important, but initially, non-verbal support through physical presence can be comforting. Leaving the client alone to cry (choice C) can make the client feel abandoned and unsupported during a vulnerable moment. Ignoring the client's crying (choice D) is not appropriate and lacks compassion and empathy, which are crucial in end-of-life care.

4. When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?

• A. Determine if the expected outcomes were realistic
• B. Obtain current client data to compare with expected outcomes
• C. Modify the nursing interventions to achieve the client's goals
• D. Review related professional standards of care

Correct answer: B

Rationale: After reviewing the expected outcomes in the plan of care, the nurse should obtain current client data to compare with these outcomes. This step is crucial in determining the effectiveness of the care provided. Choice A is incorrect because determining the realism of expected outcomes comes after assessing current client data. Choice C is incorrect as modifying nursing interventions should be based on the data comparison rather than done immediately after reviewing expected outcomes. Choice D is also incorrect as reviewing professional standards of care is important but not the immediate next step in evaluating care effectiveness.

5. The nurse is caring for a client with diabetes insipidus. Which finding should the LPN/LVN report to the healthcare provider?

• A. Weight gain
• B. Increased urine output
• C. Low blood pressure
• D. Thirst

Correct answer: B

Rationale: The correct answer is B: Increased urine output. In diabetes insipidus, there is a deficiency of antidiuretic hormone (ADH), leading to the excretion of large amounts of dilute urine. Reporting increased urine output is crucial as it is a hallmark sign of diabetes insipidus. Weight gain (choice A) is not typically associated with diabetes insipidus; instead, clients may experience weight loss due to fluid loss. Low blood pressure (choice C) can be a complication of diabetes insipidus due to dehydration from excessive urination, but the priority finding to report is the increased urine output. Thirst (choice D) is a common symptom of diabetes insipidus due to the body's attempt to compensate for fluid loss, but it is not the most critical finding to report.

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