Nursing Elites

1. When planning care for a client on mechanical ventilation, which mode of ventilation that increases the effort of the client's respiratory muscles should NOT be included in the plan of care?

• A. Assist-control
• B. Synchronized intermittent mandatory ventilation
• C. Continuous positive airway pressure
• D. Pressure support ventilation

Correct answer: A

Rationale: Assist-control ventilation mode delivers a preset tidal volume at a set rate; however, it may not be suitable for clients who need to maintain some level of respiratory muscle activity. This mode provides full support for each breath, potentially leading to decreased respiratory muscle strength over time. Therefore, it is important to avoid using assist-control mode for clients who require increased effort of respiratory muscles to prevent muscle atrophy and promote optimal respiratory function.

2. While caring for a client in a clinic, a healthcare professional learns that the client woke up not recognizing their partner, surroundings, has chills, and chest pain worsening upon inspiration. What should be the healthcare professional's priority action?

• A. Obtain baseline vital signs and oxygen saturation.
• B. Obtain a sputum culture.
• C. Obtain a complete history from the client.
• D. Provide a pneumococcal vaccine.

Correct answer: A

Rationale: The priority action for the healthcare professional is to obtain the client's baseline vital signs and oxygen saturation. This will provide essential information on the client's current physiological status and help guide further assessment and intervention. Assessing the vital signs and oxygen saturation can help identify any immediate concerns like hypoxia or sepsis, which require prompt attention. While obtaining a complete history and considering a pneumococcal vaccine may be important in the overall care of the client, assessing the vital signs and oxygen saturation takes precedence to address the client's immediate physiological needs.

3. What term refers to the manner of walking?

• A. Gait
• B. Range of motion
• C. Flexion and extension
• D. Hopping

Correct answer: A

Rationale: Gait specifically refers to the manner in which a person walks. It encompasses the pattern, rhythm, and style of walking, making it the most appropriate term in this context. Choices B, C, and D are incorrect. Range of motion refers to the extent of movement of a joint, flexion and extension relate to bending and straightening movements at a joint, and hopping is a specific type of movement that involves jumping on one foot.

4. When creating a plan of care for a newly admitted client with obsessive-compulsive disorder, which of the following interventions should the nurse take?

• A. Allow the client enough time to perform rituals
• B. Give the client autonomy in scheduling activities
• C. Discourage the client from exploring irrational fears
• D. Provide negative reinforcement for ritualistic behaviors

Correct answer: A

Rationale: Individuals with obsessive-compulsive disorder often feel compelled to perform rituals to alleviate anxiety. Allowing the client enough time to perform these rituals can help reduce their anxiety levels and promote a sense of control. Providing autonomy in scheduling activities can also empower the client and enhance their sense of independence. Discouraging exploration of irrational fears may increase anxiety and worsen symptoms. Negative reinforcement for ritualistic behaviors is not recommended as it can be counterproductive and reinforce the behavior.

5. The client was asked to read the Snellen chart. Which of the following is being tested?

• A. Optic
• B. Olfactory
• C. Oculomotor
• D. Trochlear

Correct answer: A

Rationale: The correct answer is A: Optic. The Snellen chart is used to test visual acuity, which assesses the function of the optic nerve responsible for vision. Choices B, C, and D are incorrect. Olfactory relates to the sense of smell, oculomotor controls eye movement, and trochlear controls certain eye muscles. Therefore, the only option related to vision testing in this context is the optic nerve.

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