Nursing Elites

1. A nurse is collecting data from an older adult client as part of a neurologic examination. Which of the following findings should the nurse expect as changes associated with aging?

• A. Slower light touch sensation
• B. Some vision and hearing decline
• C. Slower fine finger movement
• D. Some short-term memory decline

Correct answer: B

Rationale: As individuals age, it is common to experience changes in vision and hearing, leading to some decline in these senses. Slower light touch sensation and slower fine finger movement are also typical findings associated with aging. However, some short-term memory decline is more closely related to cognitive aging rather than typical age-related changes in the neurologic system. Therefore, the correct answer is the decline in vision and hearing. Decreased risk of depression is not a typical finding in aging; in fact, the risk of depression may increase as individuals age.

2. When measuring a client's blood pressure, which approach is the priority for a nurse caring for a client with hypertension?

• A. Obtain the blood pressure under the same conditions each time
• B. Use a different arm for each measurement
• C. Measure the blood pressure while the client is standing
• D. Take multiple readings at different times of the day

Correct answer: A

Rationale: The correct approach when measuring a client's blood pressure, especially for a client with hypertension, is to obtain the blood pressure under the same conditions each time. Consistency in measurement conditions helps ensure accurate and comparable blood pressure readings. Using a different arm for each measurement (Choice B) is not ideal as it can lead to variations in readings. Measuring the blood pressure while the client is standing (Choice C) is not the standard practice and may not provide accurate results. Taking multiple readings at different times of the day (Choice D) may be useful for monitoring blood pressure trends but is not the priority when ensuring accurate individual readings.

3. A client is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?

• A. Reassure the client that this is an expected response to grief.
• B. Ignore the client’s anger and continue with the plan of care.
• C. Tell the client that anger is not going to help his situation.
• D. Encourage the client to express his anger.

Correct answer: A

Rationale: When a client is expressing anger about a diagnosis, it is essential for the nurse to validate the client's feelings. Choice A is correct because reassuring the client that anger is an expected response to grief acknowledges the client's emotions and encourages expression, fostering a therapeutic relationship. This validation helps the client feel understood and supported during a challenging time. Choice B is incorrect as ignoring the client's anger can lead to feelings of neglect and hinder effective communication, which is crucial for providing holistic care. Choice C is inappropriate because telling the client that anger is not helpful dismisses the client's emotions and can further escalate the situation, potentially damaging the nurse-client relationship. Choice D is not the best option as it does not involve acknowledging the client's feelings or providing support and validation, which are vital in promoting emotional well-being and trust between the client and the nurse.

4. In planning care for a client with a surgical wound healing by secondary intention, the nurse can anticipate that the client will:

• A. Be at an increased susceptibility for infection
• B. Have a wound that heals more slowly
• C. Experience more pain during the healing process
• D. Require more frequent dressing changes

Correct answer: A

Rationale: Wounds healing by secondary intention involve the gradual filling of the wound with granulation tissue, leading to a higher risk of infection due to prolonged exposure. This makes choice A the correct answer. Choices B and C are incorrect because wounds healing by secondary intention take longer to heal and often result in more pain compared to wounds healing by primary intention. Choice D is also incorrect as wounds healing by secondary intention usually require more frequent dressing changes to prevent infection and promote healing.

5. A 2-year-old child is brought to the health care provider's office with a chief complaint of mild diarrhea for 2 days. Nutritional counseling by the nurse should include which statement?

• A. Place the child on clear liquids and gelatin for 24 hours
• B. Continue with the regular diet and include oral rehydration fluids
• C. Give bananas, apples, rice, and toast as tolerated
• D. Place NPO for 24 hours, then rehydrate with milk and water

Correct answer: B

Rationale: In managing mild diarrhea in a 2-year-old child, it is important to maintain their regular diet and include oral rehydration fluids. Choice A of placing the child on clear liquids and gelatin for 24 hours may not provide adequate nutrition and can lead to further electrolyte imbalances. Choice C of giving bananas, apples, rice, and toast as tolerated is a part of the BRAT diet, which is not recommended as the primary approach anymore due to its limited nutritional value. Choice D of placing the child NPO for 24 hours and then rehydrating with milk and water is not appropriate as it can worsen dehydration and delay recovery. Therefore, the best option is to continue the child's regular diet while incorporating oral rehydration fluids to prevent dehydration and maintain nutritional status.

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