Nursing Elites

1. A client is being monitored for decreased tissue perfusion and increased risk of skin breakdown. Which measure best improves tissue perfusion in this client?

• A. Massaging the reddened areas
• B. Performing range of motion exercises
• C. Administering antithrombotics as ordered
• D. Feeding the client a high-carbohydrate diet

Correct answer: B

Rationale: For a client at risk of impaired skin integrity due to decreased tissue perfusion, improving mobility is crucial to enhance tissue perfusion and prevent skin breakdown. Range of motion exercises are beneficial to increase circulation and prevent complications. Massaging reddened areas may further damage fragile skin. Administering antithrombotics may be necessary for specific conditions but does not directly address tissue perfusion. Feeding a high-carbohydrate diet does not directly improve tissue perfusion in this context.

2. Which of the following is an example of intrapersonal conflict?

• A. A nurse feels guilty when she administers essential medication that causes a client to have nausea and vomiting
• B. A nurse is called to testify in court about a client she cared for three years ago
• C. A nurse feels guilty for working overtime
• D. A nurse faces a conflict with a colleague over patient care decisions

Correct answer: A

Rationale: Intrapersonal conflict involves negative feelings or frustrations within oneself. It may be related to decisions or actions that clash with personal morals or beliefs. Choice A is the correct answer because the nurse is experiencing guilt due to administering medication that causes a client to have negative side effects, which reflects an internal struggle. Choices B, C, and D do not represent intrapersonal conflict. Choice B involves a legal obligation, Choice C is related to external factors like working overtime, and Choice D pertains to a conflict with a colleague.

3. Examples of preservation of self-integrity include all of the following except:

• A. Using assistive equipment to move bariatric clients
• B. Participating in wellness programs
• C. Accepting the challenge of caring for clients with oppositional beliefs or practices
• D. Using hand hygiene and personal protective equipment

Correct answer: C

Rationale: Preservation of self-integrity involves actions that support the nurse's well-being and ethical standards. Using assistive equipment to move bariatric clients and practicing hand hygiene and personal protective equipment are essential aspects of maintaining physical health and safety, contributing to self-care. Participating in wellness programs further enhances self-care by promoting overall well-being. However, accepting the challenge of caring for clients with oppositional beliefs or practices can be emotionally taxing and may compromise a nurse's self-integrity if it leads to significant moral distress or ethical conflicts. In such situations, it is important for nurses to prioritize their well-being and ethical values by seeking alternative solutions or support.

4. Mr. W has orders for a physical therapy consult. The nurse contacts the appropriate department but 12 hours later, no one has come to see the client. Which is the most appropriate action of the nurse?

• A. Call the supervisor and file a complaint against the physical therapy department
• B. Contact the physician to notify him that the orders were not carried out
• C. Assess the client's activity level by assisting with ambulation using a gait belt
• D. Contact the physical therapy department again and repeat the order

Correct answer: D

Rationale: In this situation, the most appropriate action for the nurse to take is to contact the physical therapy department again and repeat the order. It is crucial to ensure that the client receives the necessary care as prescribed. Following up with the department reinforces the importance of the order and increases the likelihood of prompt action. Option A is incorrect because escalating the situation to filing a complaint should be a last resort after all other communication attempts have failed. Option B is not the best course of action as the first step should be to ensure proper communication within the healthcare team. Option C is not the priority in this scenario, as the immediate concern is to address the delay in the physical therapy consult.

5. The mother of a 2-month-old infant brings the child to the clinic for a well-baby check. She is concerned because she feels only one testis in the scrotal sac. Which of the following statements about the undescended testis is the most accurate?

• A. Normally, the testes descend by one year of age.
• B. The infant will likely require surgical intervention.
• C. The infant likely has only one testis.
• D. Normally, the testes are descended by birth.

Correct answer: A

Rationale: The correct answer is that normally, the testes descend by one year of age. In young infants, it is common for the testes to retract into the inguinal canal when the environment is cold or the cremasteric reflex is stimulated. The exam should be done in a warm room with warm hands. It is most likely that both testes are present and will descend by a year. Option B is incorrect as not all cases of undescended testes require surgical intervention. Option C is incorrect because feeling only one testis does not necessarily mean the infant only has one testis. Option D is inaccurate as the testes do not normally descend by birth, but rather by one year of age. If the testes do not descend by one year, a full assessment will be needed to determine the appropriate treatment.

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