Nursing Elites

1. During a home visit, a nurse observes an older client who is attempting to ambulate to the bathroom and notes that the client is unsteady and holds onto the furniture while refusing any assistance. Which action should the nurse implement?

• A. determine home navigational safety hazards
• B. maintain the client's privacy while in the bathroom
• C. recommend that the client obtain a walker
• D. encourage the client to obtain a medical alert device

Correct answer: A

Rationale: The correct action for the nurse to implement is to determine home navigational safety hazards. In this scenario, the client is unsteady and holds onto furniture while refusing assistance, indicating a risk of falls. By identifying and addressing home safety hazards, the nurse can help prevent potential accidents. Maintaining privacy in the bathroom (Choice B) is important but not the priority in this situation. Recommending a walker (Choice C) or a medical alert device (Choice D) may be appropriate interventions later but addressing home safety hazards is the immediate concern.

2. A school nurse is developing a health risk screening protocol for use at an elementary school. What information is most important for the nurse to include in this protocol?

• A. annual flu vaccination status
• B. weight and height measurement
• C. total cholesterol level
• D. long bone deformity testing

Correct answer: B

Rationale: Weight and height measurements are crucial components of health screenings in children as they help assess growth patterns and identify potential health concerns such as obesity or growth disorders. Monitoring weight and height regularly can aid in early intervention and prevention of health issues. Annual flu vaccination status, total cholesterol level, and long bone deformity testing are not typically primary components of routine health screenings in elementary school children and may not directly contribute to identifying common health risks in this population.

3. When the receptionist for the answering service offers to take a message, which nursing action is best for the nurse to take if a client is exhibiting an extrapyramidal reaction to psychotropic medications?

• A. Leave a detailed message about the client's condition.
• B. Tell the receptionist to have the healthcare provider return the phone call.
• C. Call another healthcare provider.
• D. Document the attempt to call the healthcare provider.

Correct answer: B

Rationale: The best nursing action is to request a return call from the healthcare provider. When a client is experiencing an extrapyramidal reaction to psychotropic medications, it is crucial to prioritize the client's confidentiality and ensure the information is conveyed to the healthcare provider directly. Leaving a detailed message with a receptionist may compromise the confidentiality of the client's condition. Calling another healthcare provider may delay necessary intervention and continuity of care. Documenting the attempt to call is important for the nurse's records but does not address the immediate need to inform the healthcare provider about the client's condition.

4. A client with a history of peptic ulcer disease is admitted with sudden severe abdominal pain. Which finding indicates the possibility of a perforated ulcer?

• A. Bowel sounds are hyperactive in all quadrants.
• B. Abdomen is soft and nondistended.
• C. The client reports sudden severe abdominal pain.
• D. Blood pressure of 110/70 mm Hg.

Correct answer: C

Rationale: The correct answer is C. Sudden severe abdominal pain is a key clinical manifestation of a perforated ulcer. The sudden onset of severe pain is concerning for a perforation in the ulcer, which can lead to peritonitis if not promptly addressed. Choices A, B, and D are incorrect because hyperactive bowel sounds, a soft and nondistended abdomen, and a blood pressure of 110/70 mm Hg are not specific indicators of a perforated ulcer. Hyperactive bowel sounds may suggest increased gastrointestinal motility, a soft abdomen may not necessarily indicate a perforation, and a blood pressure of 110/70 mm Hg is within normal limits and does not directly relate to a perforated ulcer.

5. During a home visit, the nurse observes an elderly client with disabilities slip and fall. What action should the nurse take first?

• A. provide the client with 4 ounces of orange juice
• B. call 911 to summon emergency assistance
• C. check the client for lacerations or fractures
• D. assess the client's blood sugar level

Correct answer: C

Rationale: The correct action for the nurse to take first after an elderly client with disabilities slips and falls is to check the client for lacerations or fractures. This is crucial to assess the extent of injuries and provide appropriate medical attention promptly. Option A, providing orange juice, is not a priority in this situation and does not address the potential injuries. While calling 911 (Option B) may be necessary, assessing for immediate injuries takes precedence. Assessing the client's blood sugar level (Option D) is not the immediate priority after a fall unless there is a specific indication or suspicion of hypoglycemia.

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