Nursing Elites

1. A nurse is trying to motivate a client toward more effective management of a therapeutic regimen. Which of the following actions by the nurse is most likely to be effective in increasing the client's motivation?

• A. determining if the client has any family or friends living nearby
• B. developing a concise discharge plan and reviewing it with the client
• C. teaching the client about the disorder at the client's level of understanding
• D. making a referral to an area agency for client follow-up

Correct answer: C

Rationale: To effectively motivate the client, it is important to educate them about the disorder at their level of understanding. This helps the client comprehend the importance of the therapeutic regimen and empowers them to actively participate in their treatment. Choice A, determining if the client has any family or friends living nearby, may provide social support but is less likely to directly impact the client's motivation compared to educating them about their condition. Developing a concise discharge plan, as in choice B, is crucial for continuity of care but may not directly enhance the client's motivation as effectively as providing education tailored to their level of understanding. Making a referral for follow-up, as in choice D, is important for ongoing care but may not have the same immediate impact on the client's motivation as educating them about their condition.

2. Which of the following vaccines contains a live virus?

• A. varicella
• B. IPV
• C. DTaP
• D. hepatitis B

Correct answer: A

Rationale: The correct answer is varicella. Varicella vaccine contains a live, weakened form of the varicella-zoster virus. Choice B, IPV (inactivated poliovirus vaccine), is an inactivated vaccine, not a live virus vaccine. Choices C and D, DTaP (diphtheria, tetanus, and acellular pertussis vaccine) and hepatitis B vaccine, respectively, do not contain live viruses. Varicella is the only live virus vaccine among the options.

3. A healthcare professional is assisting with data collection of a client with suspected cholecystitis. Which finding does the healthcare professional expect to note if cholecystitis is present?

• A. Homan sign
• B. Murphy sign
• C. Blumberg sign
• D. McBurney sign

Correct answer: B

Rationale: The correct answer is B: Murphy sign. The Murphy sign is an indicator of gallbladder disease. It involves the examiner placing fingers under the liver border while the client inhales. If the gallbladder is inflamed, it descends onto the fingers, causing pain. The Homan sign is associated with pain in the calf area upon sharp dorsiflexion of the foot, indicating deep vein thrombosis. The Blumberg sign is the presence of rebound tenderness on palpation of the abdomen, indicating peritoneal irritation. The McBurney sign is indicative of appendicitis, presenting as severe pain and tenderness upon palpation at McBurney's point in the right lower quadrant of the abdomen.

4. A nurse helps a young adult conduct a personal lifestyle assessment. The nurse carefully reviews the assessment with the young adult for which reason?

• A. Young adults may ignore physical symptoms and postpone seeking health care
• B. Young adults are unable to afford health insurance
• C. Young adults are at risk for a serious illness
• D. Young adults are exposed to hazardous substances

Correct answer: A

Rationale: The corrected answer is A: Young adults may ignore physical symptoms and postpone seeking health care. Young adults are usually quite active, experience severe illnesses less commonly than members of older age groups, tend to ignore physical symptoms, and often postpone seeking health care. Clients in this developmental stage may benefit from a personal lifestyle assessment to identify habits that increase the risk for various chronic diseases. Choice B is incorrect because the ability to afford health insurance is not the primary reason for conducting a personal lifestyle assessment. Choice C is incorrect because young adults are not inherently at higher risk for serious illness compared to other age groups. Choice D is incorrect because exposure to hazardous substances is not the main focus when conducting a personal lifestyle assessment.

5. A paraplegic client is in the hospital to be treated for an electrolyte imbalance. Which level of care is the client currently receiving?

• A. primary prevention
• B. secondary prevention
• C. tertiary prevention
• D. health promotion

Correct answer: B

Rationale: The correct answer is B: secondary prevention. The client is currently receiving secondary prevention care. Secondary prevention focuses on early detection of disease, prompt intervention, and health maintenance for clients experiencing health problems. In this case, the electrolyte imbalance is a health problem that requires treatment to prevent further complications. Choices A, C, and D are incorrect because primary prevention is focused on health promotion and specific protections against illness before it occurs, tertiary prevention is aimed at helping rehabilitate clients after the illness is diagnosed and treated, and health promotion is a broader concept that includes activities aimed at improving overall health and well-being rather than targeting a specific health problem like an electrolyte imbalance.

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