Nursing Elites

1. An older adult client visits the community health clinic and reports the onset of pain, redness, and swelling of the right eye. Which question is most important for the clinic nurse to ask the client?

• A. Do you have any discharge from the eye?
• B. Have you started any new prescriptions?
• C. Are all of your immunizations current?
• D. How often do you wash your hands?

Correct answer: B

Rationale: The most important question for the nurse to ask the client is whether they have started any new prescriptions. New medications can have side effects that include eye issues, so it is crucial to determine if there is a potential link. Asking about discharge from the eye (Choice A) may be relevant but does not address the possibility of medication side effects. Inquiring about immunizations (Choice C) and handwashing frequency (Choice D) is important for overall health but is less directly related to the eye symptoms described by the client.

2. The healthcare professional is planning a health fair to promote cancer awareness and prevention. Which activity is most likely to increase participation?

• A. offering free cancer screenings
• B. distributing pamphlets on cancer prevention
• C. hosting a guest speaker who is a cancer survivor
• D. providing informational booths on different types of cancer

Correct answer: A

Rationale: Offering free cancer screenings is the most likely activity to increase participation in the health fair. Providing direct services such as screenings not only attracts participants but also promotes early detection, which is crucial in cancer prevention. Distributing pamphlets, hosting a guest speaker, or providing informational booths are informative but may not have the same impact in driving participation as the opportunity for free screenings.

3. During the physical assessment, which finding should the nurse recognize as a normal finding?

• A. Regular pulsation at the epigastric area when the client is supine.
• B. A loud, harsh murmur at the second right intercostal space.
• C. Dullness over the lung fields.
• D. Increased tactile fremitus.

Correct answer: A

Rationale: The regular pulsation at the epigastric area when the client is supine is a normal finding. This phenomenon is caused by the regular and recurrent expansion and contraction of an artery due to waves of pressure caused by the ejection of blood from the left ventricle. Choices B, C, and D describe abnormal findings during a physical assessment. A loud, harsh murmur at the second right intercostal space indicates an abnormal heart sound, dullness over the lung fields may suggest consolidation or fluid in the lungs, and increased tactile fremitus can be a sign of lung consolidation or pathology.

4. In conducting a health assessment for a family with a history of cardiovascular disease, which family member should be prioritized for further evaluation and intervention?

• A. a 45-year-old father who smokes and has high cholesterol
• B. a 17-year-old daughter who is overweight and inactive
• C. a 50-year-old mother with a history of hypertension
• D. a 12-year-old son who has a normal weight and is active

Correct answer: A

Rationale: The 45-year-old father who smokes and has high cholesterol is at a higher risk for cardiovascular disease due to multiple risk factors. Smoking and high cholesterol are significant contributors to the development of cardiovascular issues. Prioritizing his evaluation and intervention is crucial to address these modifiable risk factors. The other family members, though they may have risk factors as well, do not present with the same level of immediate risk based on the information provided.

5. The nurse determines that a client's body weight is 105% above the standardized height-weight scale. Which related factor should the nurse include in the nursing problem, 'Imbalanced nutrition: More than body requirements'?

• A. Hypertension.
• B. Diabetes mellitus.
• C. Inadequate lifestyle changes in diet and exercise.
• D. Increased risk of chronic illnesses.

Correct answer: C

Rationale: The correct answer is C: 'Inadequate lifestyle changes in diet and exercise.' When a client's weight exceeds the standardized height-weight scale significantly, it indicates an imbalance between nutrition intake and energy expenditure, leading to 'Imbalanced nutrition: More than body requirements.' Inadequate lifestyle changes in diet and exercise directly contribute to this imbalance by promoting excessive caloric intake and reduced physical activity. Choices A, B, and D are incorrect because while conditions like hypertension, diabetes mellitus, and increased risk of chronic illnesses may be consequences of imbalanced nutrition, they are not the direct related factor that should be included in formulating the nursing problem.

Similar Questions