Nursing Elites

1. A healthcare professional is teaching a patient how to prevent falls at home. Which instruction is most appropriate?

• A. Keep your living space well-lit.
• B. Remove loose rugs and install grab bars in the bathroom.
• C. Use furniture to provide support when walking.
• D. Wear socks without shoes to prevent slipping.

Correct answer: B

Rationale: The most appropriate instruction to prevent falls at home is to remove loose rugs and install grab bars in high-risk areas like the bathroom. This helps eliminate tripping hazards and provides stability for the patient. Keeping the living space well-lit (Choice A) is important but may not directly address fall prevention. Using furniture for support (Choice C) can lead to accidents if the furniture is not stable. Wearing socks without shoes (Choice D) increases the risk of slipping rather than preventing falls.

2. A nurse is caring for a client who is in labor and has an external fetal monitor in place. The nurse observes late decelerations in the fetal heart rate. Which of the following actions should the nurse take first?

• A. Decrease the client's IV fluids
• B. Reposition the client
• C. Administer oxygen by face mask
• D. Document the findings

Correct answer: C

Rationale: Administering oxygen by face mask is the priority intervention when late decelerations are observed in the fetal heart rate. Late decelerations indicate uteroplacental insufficiency, and administering oxygen helps to improve fetal oxygenation. Repositioning the client may also be necessary to relieve pressure on the umbilical cord, but providing oxygen takes precedence to enhance fetal oxygenation. Decreasing IV fluids may not directly address the underlying issue leading to late decelerations. Documenting the findings is important but should not be the first action taken when managing late decelerations.

3. What are the clinical manifestations of hypovolemic shock, and how should a nurse respond?

• A. Hypertension, bradycardia, and oliguria
• B. Bradycardia, hypertension, and peripheral edema
• C. Tachypnea, cool skin, and confusion
• D. Tachycardia, hypotension, and decreased urine output

Correct answer: D

Rationale: The correct answer is D: Tachycardia, hypotension, and decreased urine output are classic clinical manifestations of hypovolemic shock. In hypovolemic shock, the body tries to compensate for low blood volume by increasing the heart rate (tachycardia) to maintain cardiac output, leading to hypotension and decreased urine output. Prompt fluid replacement is necessary to restore intravascular volume. Choices A, B, and C are incorrect because they do not represent the typical manifestations of hypovolemic shock.

4. What is a key characteristic of Illness Anxiety Disorder?

• A. Excessive focus on minor symptoms without medical evidence of illness
• B. The need for consistent reassurance from healthcare professionals
• C. Compulsive behavior to avoid physical illness
• D. Development of avoidance behaviors to reduce anxiety

Correct answer: A

Rationale: The correct answer is A: "Excessive focus on minor symptoms without medical evidence of illness." Illness Anxiety Disorder, formerly known as hypochondriasis, is characterized by a preoccupation with having a serious illness despite no medical evidence to support the presence of an illness. Individuals with this disorder often interpret normal bodily sensations as signs of severe illness. Choice B is incorrect because while individuals with Illness Anxiety Disorder may seek reassurance from healthcare professionals, the excessive focus on minor symptoms is the key characteristic. Choice C is incorrect as compulsive behaviors to avoid physical illness are more characteristic of illnesses like Obsessive-Compulsive Disorder. Choice D is incorrect as the development of avoidance behaviors to reduce anxiety is more commonly seen in conditions like specific phobias or social anxiety disorder.

5. A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain?

• A. Self-report of pain
• B. Nonverbal behavior
• C. Severity of the condition
• D. Vital signs

Correct answer: A

Rationale: The correct answer is A: Self-report of pain. Pain is a subjective experience, and the most reliable way to assess it is through the client's self-report. While nonverbal behaviors and vital signs can provide additional information, they are not as reliable as the client's own report of pain. The severity of the condition may influence the experience of pain but is not a direct indicator of the client's pain level.

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