Nursing Elites

1. When developing a plan of care for a client with dementia, what should the LPN/LVN remember about confusion in the elderly?

• A. It is not a normal part of aging.
• B. It often follows relocation to new surroundings.
• C. It is primarily due to changes in the brain associated with the disease.
• D. It cannot be prevented or cured by adequate sleep alone.

Correct answer: B

Rationale: When caring for a client with dementia, it is crucial to understand that confusion often arises after relocating to new surroundings. This change can disrupt familiar routines and trigger increased disorientation and confusion. Choice A is correct because confusion in the elderly is not a normal part of aging. Choice C is incorrect because confusion in dementia is primarily due to changes in the brain associated with the disease, not just irreversible brain pathology. Choice D is incorrect because while adequate sleep is important for overall health, it alone cannot prevent or cure confusion associated with dementia.

2. A healthcare professional is caring for a group of clients. Which of the following measures should the professional take to prevent the spread of infection?

• A. Place a client with TB in a room with negative pressure airflow
• B. Use a disposable gown for contact precautions
• C. Place a client with MRSA in a private room
• D. Use a mask for clients with influenza

Correct answer: A

Rationale: Tuberculosis is an airborne infection, and placing a client with TB in a room with negative pressure airflow helps prevent the spread of the infection by containing the pathogens. This measure is crucial as it prevents the dissemination of TB droplet nuclei to other areas. Choice B, using a disposable gown for contact precautions, is important for preventing the transmission of infections spread by direct or indirect contact. Choice C, placing a client with MRSA in a private room, is essential to prevent the spread of MRSA through contact with others. Choice D, using a mask for clients with influenza, helps prevent the spread of influenza through respiratory droplets. However, negative pressure airflow is specifically required for airborne infections like TB, making it the most appropriate choice in this scenario.

3. A client with a history of heart failure presents to the clinic with a 2-day history of weight gain, swelling in the legs, and shortness of breath. Which of the following is the most appropriate initial nursing action?

• A. Perform a physical assessment
• B. Review the client's medication list
• C. Instruct the client to elevate the legs
• D. Obtain a detailed dietary history

Correct answer: A

Rationale: Performing a physical assessment is the most appropriate initial nursing action in this scenario. A thorough physical assessment helps evaluate the client's current condition, severity of symptoms, and identify any immediate concerns. This assessment can provide crucial information to guide further interventions and treatment. Reviewing the client's medication list (choice B) is important but may not address the immediate need for assessing the client's current status. Instructing the client to elevate the legs (choice C) may be beneficial but should come after a thorough assessment. Obtaining a detailed dietary history (choice D) is relevant for heart failure management but is not the most urgent initial action when the client presents with acute symptoms like weight gain, leg swelling, and shortness of breath.

4. A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process?

• A. “I will determine the most important client problems that we should address.”
• B. “I will review the past medical history on the client’s record to gather more information.”
• C. “I will carry out the new prescriptions from the provider.”
• D. “I will ask the client if their nausea has resolved.”

Correct answer: A

Rationale: In the nursing process, the planning step involves determining priorities and goals based on the identified problems. Choice A is correct as it reflects the nurse's role in identifying the most important client problems to address, which aligns with the planning phase. Choices B, C, and D are incorrect. Choice B involves data collection, which is a part of the assessment phase, not planning. Choice C pertains to the implementation of care, which occurs after the planning phase. Choice D involves evaluation of a specific intervention, not planning.

5. When planning interventions for a group of clients who are obese, what can the nurse do to improve their commitment to a long-term goal of weight loss?

• A. Developing a strict diet plan
• B. Attempting to develop the clients’ self-motivation
• C. Providing frequent rewards
• D. Encouraging group exercise

Correct answer: B

Rationale: To improve clients' commitment to a long-term goal of weight loss, attempting to develop their self-motivation is crucial. Self-motivation is essential for sustaining behavior changes over time. Providing a strict diet plan (choice A) may not address the root motivation needed for long-term success. While rewards (choice C) can be motivating, relying solely on external rewards may not foster the intrinsic motivation required for sustained weight loss. Encouraging group exercise (choice D) is beneficial, but without addressing individual motivation, it may not lead to long-term commitment to weight loss goals.

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