Nursing Elites

1. An older woman has lived alone since the death of her husband 10 years ago, and she has a long list of vague complaints. Which assessment is the priority for the home health nurse to perform?

• A. Assess for feelings of loneliness and isolation.
• B. Determine if the client has unresolved grief.
• C. Determine if there are safety issues.
• D. Ask about the availability of support systems.

Correct answer: C

Rationale: The priority assessment for the home health nurse in this scenario is to determine if there are safety issues. The client is an older woman living alone with a long list of vague complaints, indicating several risk factors. Ensuring her safety should be the primary concern. While assessing for feelings of loneliness, isolation, or grief is important, ensuring the client's safety takes precedence due to her vulnerable situation. Although assessing the availability of support systems is essential in a home health assessment, safety issues must be addressed first given the client's profile.

2. The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order?

• A. At home, I take my pills at 8:00 am.
• B. It costs a lot of money to buy all of these pills.
• C. I get so tired of taking pills every day.
• D. This is a new pill I have never taken before.

Correct answer: D

Rationale: The client stating, 'This is a new pill I have never taken before,' is the correct answer as it indicates a potential discrepancy in the medication order. This statement requires further assessment to ensure the medication is correct, verify if it is a new prescription or a different manufacturer, and determine if the client needs additional instructions. While the timing of medication administration (option A) is important, it may not be as critical as ensuring the accuracy of the medication being administered. Option B, regarding the cost of pills, is relevant for discharge planning but does not directly impact the immediate administration of the medication. Option C, expressing tiredness from taking pills daily, may warrant discussion on adherence or side effects but does not raise immediate concerns about the specific medication being administered.

3. Which basic principle of Alcoholics Anonymous (AA) should a client with alcohol use disorder follow?

• A. Spouses should attend Al-Anon meetings.
• B. It is a commitment to focus on long-term goals.
• C. Amends must be made to each person who has been harmed.
• D. People have the power to overcome alcoholism if they truly want to stop drinking.

Correct answer: C

Rationale: The correct answer is that amends must be made to each person who has been harmed. This principle is reflected in the eighth step of the 12 steps of AA, which involves making a list of all persons harmed and being willing to make amends to them. It is a fundamental principle of AA to address past harms and seek to rectify them. Choice A is incorrect because spouses attending Al-Anon meetings is not a basic principle of AA; it is a support group for family members of individuals with alcohol use disorder. Choice B is incorrect because while focusing on long-term goals can be beneficial, AA emphasizes taking one day at a time rather than committing to long-term goals. Choice D is incorrect because AA teaches that individuals struggling with alcoholism are powerless over their addiction and need to rely on a higher power rather than solely their willpower to overcome it.

4. A 65-year-old client who attends an adult daycare program and is wheelchair-mobile has redness in the sacral area. Which instruction is most important for the nurse to provide?

• A. Take a vitamin supplement tablet once a day.
• B. Change positions in the chair at least every hour.
• C. Increase daily intake of water or other oral fluids.
• D. Purchase a newer model wheelchair.

Correct answer: B

Rationale: The most important instruction for the nurse to provide to the client is to change positions in the chair at least every hour. This is crucial to prevent pressure ulcers, as prolonged pressure on the skin can lead to tissue damage. Repositioning helps relieve pressure on vulnerable areas like the sacrum. Increasing fluid intake can also aid in preventing skin breakdown by maintaining skin hydration. While a vitamin supplement may support overall health, it is not as critical as repositioning to prevent pressure ulcers. Purchasing a new wheelchair is an expensive intervention and should be considered a last resort after implementing less costly preventive measures.

5. A client who is newly diagnosed with multiple sclerosis is obviously upset and asks, 'Am I going to die?' Which response would the nurse make?

• A. Most individuals with your disease live a normal life span.
• B. Is your family here? I would like to explain your disease to all of you.
• C. The prognosis varies, as most individuals have remissions and exacerbations.
• D. Why don't you speak with your health care provider to get more details?

Correct answer: C

Rationale: The most appropriate response to the client's question regarding their prognosis is to acknowledge the variable nature of multiple sclerosis by stating that 'The prognosis varies, as most individuals have remissions and exacerbations.' This response provides realistic information while offering some hope. Choice A ('Most individuals with your disease live a normal life span.') gives false reassurance as repeated exacerbations may affect life span. Choice B ('Is your family here? I would like to explain your disease to all of you.') does not directly address the client's question and involves the family unnecessarily. Choice D ('Why don't you speak with your health care provider to get more details?') deflects the responsibility and does not address the client's immediate concerns about their prognosis.

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