Nursing Elites

1. A nurse is caring for an older adult client who is confused and continually grabs at the nurse. Which of the following is a nursing action?

• A. Firmly tell the client not to grab
• B. Redirect the client’s attention
• C. Use physical restraints
• D. Avoid contact with the client

Correct answer: B

Rationale: Redirecting the client's attention is the appropriate nursing action in this scenario. When dealing with a confused client exhibiting grabbing behavior, redirection can help shift their focus to a more appropriate activity or object. Firmly telling the client not to grab may escalate the situation and create a confrontational environment, which is not recommended when caring for confused clients. The use of physical restraints should be a last resort and only implemented after all other strategies have been exhausted, as they can contribute to increased agitation and distress in older adults. Avoiding contact with the client is not a proactive approach to managing the behavior and may lead to feelings of neglect or abandonment in the client.

2. A client is experiencing a severe sore throat, pain when swallowing, and swollen lymph nodes. Which of the following stages of infection is the client likely in?

• A. Prodromal
• B. Incubation
• C. Convalescence
• D. Illness

Correct answer: D

Rationale: The client in this scenario is in the illness stage of infection. During this stage, the individual exhibits specific symptoms such as a severe sore throat, pain when swallowing, and swollen lymph nodes. The prodromal stage precedes the appearance of specific symptoms and is characterized by nonspecific signs. The incubation period occurs between exposure to the pathogen and the onset of symptoms. Convalescence is the recovery period following the resolution of the infection. Therefore, the correct answer is 'D: Illness' as it aligns with the symptoms presented by the client.

3. The patient is being treated for cancer with weekly radiation therapy to the head and intravenous chemotherapy treatments. Which assessment is the priority?

• A. Feet
• B. Nail beds
• C. Perineum
• D. Oral cavity

Correct answer: D

Rationale: The correct answer is the oral cavity. During cancer treatment involving radiation to the head and intravenous chemotherapy, the oral cavity is a priority assessment area. Radiation can reduce salivary flow and lower the pH of saliva, which can lead to stomatitis and tooth decay. Assessing the oral cavity allows for the early identification and management of potential complications. Choice A, assessing the feet, is not the priority in this scenario as it is not directly impacted by the described cancer treatments. Choice B, assessing the nail beds, is not the priority compared to the oral cavity. Nail bed assessment may be relevant for certain conditions, but in this case, the oral cavity is of higher priority due to the specific treatment effects. Choice C, assessing the perineum, is also not the priority in this situation as it is not directly affected by the described cancer treatments, unlike the oral cavity.

4. A provider prescribes cold application for a client who reports ankle joint stiffness. Which of the following assessment findings should the nurse identify as a contraindication to the application of cold?

• A. Capillary refill of 4 seconds
• B. 7.5 cm (3 in) diameter bruise on the ankle
• C. Warts on the affected ankle
• D. 2+ pitting edema

Correct answer: A

Rationale: The correct answer is A. Capillary refill of 4 seconds indicates poor circulation, which is a contraindication to cold application as it could worsen the condition by further reducing blood flow. Choice B, a 7.5 cm (3 in) diameter bruise on the ankle, does not directly contraindicate cold application but may need evaluation for possible underlying injuries. Choice C, warts on the affected ankle, do not necessarily contraindicate cold application. Choice D, 2+ pitting edema, is not a direct contraindication to cold application but may need to be addressed separately.

5. The healthcare professional is preparing to administer an intramuscular injection to an adult client. Which site is most appropriate for the LPN/LVN to use?

• A. Deltoid muscle
• B. Ventrogluteal site
• C. Dorsogluteal site
• D. Rectus femoris site

Correct answer: B

Rationale: The ventrogluteal site is the most appropriate and safest site for administering an intramuscular injection to an adult client. It is preferred due to its thick muscle mass and fewer major blood vessels and nerves in the area, reducing the risk of injury or complications. The deltoid muscle is commonly used for vaccines and small-volume injections but may not be suitable for larger volumes. The dorsogluteal site has fallen out of favor due to the risk of injury to the sciatic nerve and other underlying structures. The rectus femoris site is not typically used for intramuscular injections in adults.

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