Nursing Elites

1. A nurse is teaching a client who has peripheral arterial disease (PAD) about exercise recommendations. Which of the following instructions should the nurse include?

• A. Exercise to the point of pain
• B. Stop exercising if pain occurs
• C. Exercise only once per week
• D. Avoid walking to prevent pain

Correct answer: B

Rationale: The correct instruction the nurse should include is to 'Stop exercising if pain occurs.' In peripheral arterial disease (PAD), it is crucial to avoid exercising to the point of pain as this may worsen the condition and lead to complications. Exercising to the point of pain can result in inadequate blood flow to the extremities, causing further damage. By stopping exercise if pain occurs, the client can prevent exacerbating their condition. Choices A, C, and D are incorrect because exercising to the point of pain, limiting exercise to once per week, and avoiding walking altogether are not recommended strategies for managing PAD and could potentially harm the client.

2. After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a five-year-old child is admitted to the emergency room. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessments, if observed by the nurse three hours after admission, should be reported to the physician?

• A. The client has slight edema of the eyelids
• B. There is clear fluid draining from the client's right ear
• C. There is some bleeding from the child's lacerations
• D. The client withdraws in response to painful stimuli

Correct answer: B

Rationale: Clear fluid draining from the ear can indicate cerebrospinal fluid leakage, which is a serious concern after a head injury. This leakage can signify a skull fracture or damage to the meninges, potentially leading to infection. Therefore, it should be reported immediately for further evaluation and management. Choices A, C, and D are typical findings after head trauma and are not as urgent as the presence of clear fluid draining from the ear.

3. A nurse is reinforcing teaching about home care for conjunctivitis with the parent of a school-age child. Which of the following information should the nurse include?

• A. Use a separate washcloth for the child
• B. Apply cold compresses to the eyes
• C. Apply warm compresses to the eyes
• D. Keep the child home until symptoms have resolved

Correct answer: A

Rationale: The correct answer is to use a separate washcloth for the child. This is important to prevent the spread of infection when a child has conjunctivitis. Using the same washcloth can lead to cross-contamination and further spread of the condition. Applying cold or warm compresses may provide comfort but do not address the prevention of spreading the infection. Keeping the child home until symptoms have resolved may be necessary, but the primary focus should be on preventing the spread of the infection within the household.

4. A nurse is teaching a client who is taking warfarin about food and medication interactions. Which of the following foods should the nurse instruct the client to avoid?

• A. Tomatoes
• B. Apples
• C. Broccoli
• D. Green leafy vegetables

Correct answer: D

Rationale: Correct Answer: Green leafy vegetables - Green leafy vegetables are high in vitamin K, which can interfere with the effectiveness of warfarin. Tomatoes, apples, and broccoli are not contraindicated with warfarin therapy. While they are healthy choices, they do not have a significant impact on warfarin's effectiveness.

5. A nurse is assessing a client who has a brainstem injury. The nurse should expect the client to exhibit which of the following findings?

• A. Decerebrate posturing.
• B. Hypervigilance.
• C. Absence of deep tendon reflexes.
• D. Glasgow Coma Scale score of 15.

Correct answer: A

Rationale: The correct answer is A: Decerebrate posturing. Decerebrate posturing is an abnormal body posture characterized by rigid extension of the arms and legs, which indicates severe brainstem injury affecting the midbrain and pons. This posture suggests dysfunction or damage to neural pathways controlling muscle tone. Choice B, hypervigilance, is not typically associated with brainstem injury but rather with increased alertness and arousal. Choice C, absence of deep tendon reflexes, is not a specific finding related to brainstem injury. Choice D, a Glasgow Coma Scale score of 15, indicates a fully awake and alert state, which is not expected in a client with a brainstem injury.

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