Nursing Elites

1. A client is receiving teaching from a healthcare provider about reducing the adverse effects of immobility. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will perform ankle and knee exercises every hour - Range of motion (ROM) is needed to prevent contractures.
• B. I will hold my breath when rising from a sitting position.
• C. I will remove my antiembolic stockings while I am in bed.
• D. I will have my partner help me change positions every 4 hours.

Correct answer: A

Rationale: Choice A is correct because performing ankle and knee exercises every hour helps prevent contractures and other adverse effects of immobility. Contractures are a common complication of immobility, and range of motion (ROM) exercises can help maintain joint flexibility and prevent contractures. This statement indicates an understanding of the teaching provided by the healthcare provider. Choices B, C, and D are incorrect. Holding the breath when rising from a sitting position can increase the risk of orthostatic hypotension, not reduce adverse effects of immobility. Removing antiembolic stockings while in bed can compromise their effectiveness in preventing deep vein thrombosis (DVT), which is not a measure to reduce immobility-related complications. Having a partner help change positions every 4 hours may not be frequent enough to prevent immobility-related complications effectively; changing positions more frequently is usually recommended to prevent issues like pressure ulcers and muscle stiffness.

2. A client with difficulty self-feeding due to rheumatoid arthritis should be referred to which member of the interprofessional care team to use adaptive devices?

• A. Social worker
• B. Certified nursing assistant
• C. Registered dietitian
• D. Occupational therapist

Correct answer: D

Rationale: The correct answer is D, Occupational therapist. Occupational therapists specialize in assisting clients with adaptive devices to enhance their ability to perform daily activities like self-feeding. They evaluate client needs and provide interventions to promote independence in activities of daily living. Choice A, Social worker, focuses on psychosocial support and community resources, not directly addressing the physical aspect of self-feeding difficulty. Choice B, Certified nursing assistant, is involved in direct patient care but lacks specialized training in adaptive devices. Choice C, Registered dietitian, primarily focuses on nutrition-related issues and may not have the expertise in adaptive devices and functional rehabilitation necessary for this client's self-feeding challenges.

3. A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse to a complication of this condition?

• A. Dyspnea
• B. Heart murmur
• C. Macular rash
• D. Hemorrhage

Correct answer: B

Rationale: A new or changed heart murmur is a common sign of valve involvement in infective endocarditis, indicating a complication such as valve damage or regurgitation. Dyspnea is more commonly associated with respiratory or cardiac conditions not directly related to infective endocarditis. A macular rash is not a typical symptom of infective endocarditis, suggesting other conditions like infectious diseases. Hemorrhage is not a direct complication of infective endocarditis but may occur due to factors such as anticoagulant therapy or underlying bleeding disorders.

4. What immediate action should a healthcare worker take after being stuck in the hand by an exposed needle?

• A. Look up the policy on needle sticks
• B. Contact employee health services
• C. Immediately wash the hands thoroughly with soap and water
• D. Notify the supervisor and risk management

Correct answer: C

Rationale: The correct immediate action for a healthcare worker who has been stuck by an exposed needle is to wash the hands thoroughly with soap and water to reduce the risk of infection. This helps to remove any potential pathogens introduced by the needle stick. Looking up the policy on needle sticks (Choice A) is important but not the immediate action required. Contacting employee health services (Choice B) and notifying the supervisor and risk management (Choice D) are crucial steps to take, but they should follow the initial step of washing the hands to mitigate the risk of infection.

5. A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells the client that diapers will be used next time the urinal is used improperly. Which of the following torts is the AP committing?

• A. Assault
• B. Battery
• C. False imprisonment
• D. Invasion of privacy

Correct answer: A

Rationale: The correct answer is A: Assault. Assault involves making threats or using actions that cause the client to fear harm. In this scenario, the AP's threat to use diapers next time the urinal is used improperly constitutes as assault. Choice B, Battery, involves intentional harmful or offensive touching without consent, which is not evident in the scenario. Choice C, False imprisonment, refers to restraining or restricting a client's freedom of movement, which is not occurring in this situation. Choice D, Invasion of privacy, involves violating a client's right to privacy, which is also not applicable here.

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