Nursing Elites

1. During an assessment, a healthcare professional is evaluating the body alignment of a standing patient. Which finding will the healthcare professional report as normal?

• A. When observed laterally, the spinal curves align in a reversed 'S' pattern.
• B. When observed posteriorly, the hips and shoulders form an 'S' pattern.
• C. The arms should be crossed over the chest or in the lap.
• D. The feet should be close together with toes pointed out.

Correct answer: A

Rationale: During a standing assessment, the healthcare professional should observe the patient laterally. In a normal body alignment, the head is erect, and the spinal curves align in a reversed 'S' pattern, aiding in maintaining balance and posture. Choice B is incorrect because hips and shoulders should be level and not form an 'S' pattern when observed posteriorly. Choice C is incorrect as the position of the arms is not a key indicator of body alignment. Choice D is incorrect as the feet should be shoulder-width apart with toes pointing forward for optimal balance and stability.

2. A healthcare professional is caring for a group of clients. Which of the following measures should the professional take to prevent the spread of infection?

• A. Place a client with TB in a room with negative pressure airflow
• B. Use a disposable gown for contact precautions
• C. Place a client with MRSA in a private room
• D. Use a mask for clients with influenza

Correct answer: A

Rationale: Tuberculosis is an airborne infection, and placing a client with TB in a room with negative pressure airflow helps prevent the spread of the infection by containing the pathogens. This measure is crucial as it prevents the dissemination of TB droplet nuclei to other areas. Choice B, using a disposable gown for contact precautions, is important for preventing the transmission of infections spread by direct or indirect contact. Choice C, placing a client with MRSA in a private room, is essential to prevent the spread of MRSA through contact with others. Choice D, using a mask for clients with influenza, helps prevent the spread of influenza through respiratory droplets. However, negative pressure airflow is specifically required for airborne infections like TB, making it the most appropriate choice in this scenario.

3. A nurse is assigned to a manipulative client for 5 days and becomes aware of feelings of reluctance to interact with the client. What should the nurse do next?

• A. Discuss the feelings of reluctance with an objective peer or supervisor
• B. Limit contacts with the client to avoid reinforcement of the manipulative behavior
• C. Confront the client about the negative effects of behaviors on other clients and staff
• D. Develop a behavior modification plan that will promote more functional behavior

Correct answer: A

Rationale: It is important for the nurse to address their feelings of reluctance when dealing with a manipulative client by discussing them with an objective peer or supervisor. This action can provide valuable insight and support for managing the nurse-client relationship. Choice B should be avoided as limiting contacts with the client may not address the underlying issues and could potentially harm the therapeutic relationship. Choice C is confrontational and may escalate the situation rather than resolve it. Choice D, while important, should come after addressing the nurse's feelings and seeking support.

4. A female client with chronic back pain has been taking muscle relaxants and analgesics to manage the discomfort, but is now experiencing an acute episode of pain that is not relieved by this medication regime. The client tells the nurse that she does not want to have back surgery for a herniated intervertebral disk, and reports that she has found acupuncture effective in resolving past acute episodes. Which response is best for the nurse to provide?

• A. Surgery removes the disk and is the only treatment that can totally resolve the pain
• B. The medication regimen you previously used should be re-evaluated for dose adjustment
• C. Massage and hot pack treatments are less invasive and can provide temporary relief
• D. Acupuncture is a complementary therapy that is often effective for management of pain

Correct answer: D

Rationale: Acupuncture has been effective for the client previously, supporting continued use.

5. When admitting a 5-month-old who has vomited 9 times in the past 6 hours, what should the healthcare provider observe for signs of which overall imbalance?

• A. Metabolic acidosis
• B. Metabolic alkalosis
• C. Increased serum hemoglobin levels
• D. Decreased serum potassium levels

Correct answer: B

Rationale: When a 5-month-old infant vomits multiple times, there is a risk of developing metabolic alkalosis due to the loss of stomach acid. Metabolic alkalosis is characterized by elevated pH and bicarbonate levels. It is caused by the loss of hydrogen ions from the body, often through vomiting. Metabolic acidosis (choice A) is unlikely in this scenario because it is more commonly associated with conditions like renal failure or diabetic ketoacidosis. Choice C, increased serum hemoglobin levels, is not typically a direct consequence of vomiting. Choice D, decreased serum potassium levels, may occur with vomiting but is not the primary concern when a patient is vomiting excessively.

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