Nursing Elites

1. A client is still experiencing mild back pain after receiving analgesia 1 hour ago. Which of the following nonpharmacological pain management techniques should the nurse include in the plan?

• A. Encourage the client to apply a heating pad for 2 hours at a time
• B. Apply an ice pack to the client’s back for 1 hour
• C. Remove distractions from the client’s room
• D. Instruct the client to take deep, rhythmic breaths

Correct answer: D

Rationale: In this scenario, the nurse should instruct the client to take deep, rhythmic breaths as a nonpharmacological pain management technique. Deep, rhythmic breathing helps with relaxation and pain management, potentially reducing the perception of pain. Encouraging the client to apply a heating pad for 2 hours at a time (Choice A) is not recommended as prolonged heat application can lead to tissue damage and is not suitable for mild back pain. Applying an ice pack for 1 hour (Choice B) may not be appropriate for mild back pain as cold therapy is more commonly used for acute injuries. Removing distractions from the client’s room (Choice C) may help create a more calming environment, but it does not directly address the client's pain.

2. A charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which of the following examples should the charge nurse include as a developmental task for a young adult?

• A. Becoming actively involved in providing guidance to the next generation.
• B. Adjusting to major changes in roles and relationships due to losses.
• C. Devoting time to establishing an occupation.
• D. Finding oneself 'sandwiched' between and being responsible for two generations.

Correct answer: C

Rationale: The correct answer is C: Devoting time to establishing an occupation. Young adults typically focus on building their careers and personal identities, making establishing an occupation a crucial developmental task for this age group. Choices A, B, and D do not align with the typical developmental tasks of young adults. Choice A relates more to middle adulthood where individuals take on mentoring roles, choice B is more characteristic of the tasks associated with adjusting to late adulthood, and choice D is more relevant to middle adulthood when individuals may find themselves caring for both their own children and aging parents.

3. A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit, and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess?

• A. Bounding pulse
• B. Decreased blood pressure
• C. Dry mucous membranes
• D. Weak pulse

Correct answer: A

Rationale: A bounding pulse is indicative of fluid volume excess. In this case, the client's weight gain and edematous ankles already suggest fluid volume overload. A bounding pulse occurs due to increased blood volume and pressure. Choices B, C, and D are not indicative of fluid volume excess. Decreased blood pressure, dry mucous membranes, and weak pulse are more commonly associated with conditions such as dehydration or hypovolemia, where there is a decrease in fluid volume rather than an excess.

4. A nurse is caring for a young adult at a college health clinic. Which of the following actions should the nurse take first?

• A. Give the client information about immunization against meningitis.
• B. Tell the client to have a TB skin test every 2 years.
• C. Determine the client’s health risks.
• D. Teach the client about exercise recommendations.

Correct answer: C

Rationale: Assessing the client’s health risks is the priority as it provides essential information to guide subsequent care. By understanding the client’s health risks, the nurse can tailor health education and interventions, such as immunizations and lifestyle modifications, to address specific needs. Providing information about immunization against meningitis (Choice A) is important but should come after assessing health risks. Instructing the client to have a TB skin test every 2 years (Choice B) is relevant but not the initial step in care. Teaching about exercise recommendations (Choice D) is also essential but should follow the assessment of health risks.

5. A healthcare professional is assessing a patient's skin. Which patient is most at risk for impaired skin integrity?

• A. A patient who is afebrile
• B. A patient who is diaphoretic
• C. A patient with strong pedal pulses
• D. A patient with adequate skin turgor

Correct answer: B

Rationale: Excessive moisture on the skin, as seen in a diaphoretic patient, can lead to impaired skin integrity. Diaphoresis softens epidermal cells, promotes bacterial growth, and can cause skin maceration. Afebrile status, strong pedal pulses, and adequate skin turgor are not directly associated with an increased risk of impaired skin integrity. Afebrile indicates the absence of fever, not a risk to skin integrity. Strong pedal pulses suggest good circulation, which is beneficial for skin health. Adequate skin turgor is a sign of good hydration and skin elasticity, indicating a lower risk of impaired skin integrity.

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