Nursing Elites

1. An infant is being administered an immunization. Which of the following provides an accurate description of an immunization?

• A. It should be administered to a pregnant woman prior to the infant's birth.
• B. It is the administration of an antigen to stimulate an antibody response.
• C. It produces many adverse reactions, particularly autism, in the infant.
• D. It protects the infant from exposure to infectious antibodies.

Correct answer: B

Rationale: The correct answer is B. Immunization involves administering an antigen, such as a weakened or killed microorganism, to stimulate the immune system to produce an antibody response. This process helps the body recognize and remember specific pathogens, providing immunity against future infections. Choice A is incorrect because immunizations are administered to the infant directly, not to the pregnant woman before birth. Choice C is incorrect as there is no scientific evidence linking immunizations to autism. Choice D is incorrect as immunizations protect against infectious agents, not antibodies.

2. A man with gout has developed large, hard nodules around his toes and elbows. The phase of gout he is in is:

• A. asymptomatic
• B. acute flare
• C. the intercritical period
• D. chronic gout

Correct answer: D

Rationale: The correct answer is 'chronic gout.' Chronic gout is characterized by the presence of tophi, which are large, hard nodules that can develop around joints like toes and elbows. These tophi are a sign of longstanding, untreated gout. Choice A, 'asymptomatic,' is incorrect as the presence of tophi indicates a symptomatic phase. Choice B, 'acute flare,' is incorrect as acute flares are characterized by sudden and severe pain, inflammation, and redness in the joints, not the development of tophi. Choice C, 'the intercritical period,' is also incorrect as this phase occurs between acute attacks and is typically asymptomatic, without the presence of tophi.

3. What assessment is the nurse performing when a client is asked to stand with feet together, eyes open, and hands by the sides, and then asked to close the eyes while the nurse observes for a full minute?

• A. Romberg test
• B. Weber test
• C. Rinne test
• D. Babinski test

Correct answer: A

Rationale: The correct answer is A, Romberg test. The Romberg test is used to assess balance and proprioception. During the test, the client is asked to stand with feet together, eyes open, and hands by the sides to observe their balance. Then, the client is asked to close their eyes while the nurse continues to observe for a full minute. This test helps in detecting any issues with proprioception and balance, which may be compromised in conditions affecting the nervous system. Choices B, C, and D are incorrect because the Weber test is used to assess hearing in each ear, the Rinne test is used to compare air and bone conduction of sound, and the Babinski test is used to assess the integrity of the corticospinal tract.

4. A nurse is educating a client with peripheral artery disease (PAD). Which statement made by the client indicates a need for further teaching?

• A. I should avoid walking for long periods to prevent leg pain.
• B. I should inspect my feet daily for any sores or wounds.
• C. I should wear compression stockings to improve circulation.
• D. I should avoid smoking to prevent further damage to my arteries.

Correct answer: A

Rationale: The correct answer is A. Walking is crucial in improving circulation in peripheral artery disease; therefore, the client should not avoid walking for long periods. Choices B, C, and D are correct statements for a client with PAD. Inspecting feet daily helps in early detection of sores or wounds, wearing compression stockings improves circulation, and avoiding smoking helps prevent further damage to arteries in PAD.

5. During the home visit of a client with dementia, the nurse notes that an adult daughter persistently corrects her father’s misperceptions of reality, even when the father becomes upset and anxious. Which intervention should the nurse teach the caregiver?

• A. Anxiety-reducing measures
• B. Positive reinforcement
• C. Reality orientation techniques
• D. Validation techniques

Correct answer: D

Rationale: The correct answer is D: Validation techniques. In dementia care, using validation techniques involves acknowledging the person's feelings and reality, even if it differs from actual events or facts. It helps in reducing the client's anxiety and distress. In this scenario, the daughter persistently correcting her father's misperceptions can escalate his anxiety. Teaching the daughter validation techniques will encourage her to validate her father's feelings and perceptions, ultimately promoting a more supportive and less confrontational environment. Choices A, B, and C are incorrect in this context. While anxiety-reducing measures can be beneficial, the primary issue here is the father's misperceptions being consistently corrected. Positive reinforcement focuses on rewarding desired behaviors, which is not directly related to the situation described. Reality orientation techniques involve constantly reminding the person of the correct time, place, and other details, which may not be suitable for someone with dementia experiencing distress.

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