Nursing Elites

1. In which condition is the 'butterfly rash' most commonly seen?

• A. Systemic lupus erythematosus
• B. Rheumatoid arthritis
• C. Psoriasis
• D. Dermatomyositis

Correct answer: A

Rationale: The correct answer is A: Systemic lupus erythematosus (SLE). The 'butterfly rash' across the cheeks and nose is a classic sign of SLE, an autoimmune disease. This rash is a key dermatological manifestation of SLE, often triggered or worsened by exposure to sunlight. Choices B, C, and D are incorrect because the 'butterfly rash' is not commonly associated with rheumatoid arthritis, psoriasis, or dermatomyositis.

2. What is the most common genetic cause of intellectual disability?

• A. Down syndrome
• B. Fragile X syndrome
• C. Prader-Willi syndrome
• D. Turner syndrome

Correct answer: B

Rationale: The correct answer is Fragile X syndrome because it is the most common inherited cause of intellectual disability, resulting from a mutation in the FMR1 gene. Down syndrome, Prader-Willi syndrome, and Turner syndrome are not the most common genetic causes of intellectual disability. Down syndrome is caused by the presence of an extra chromosome 21, Prader-Willi syndrome results from specific genetic abnormalities on chromosome 15, and Turner syndrome is characterized by the absence of part or all of one of the X chromosomes.

3. A client with a prescription for a transcutaneous electrical nerve stimulator (TENS) unit for pain management asks how it works. What information should the nurse reinforce?

• A. The discharge of electricity will distract the client's focus from the pain
• B. An infusion of medication in the spinal canal will block pain perception
• C. Pain perception in the cerebral cortex is dulled by the unit's discharge of an electrical stimulus
• D. A mild electrical stimulus on the skin surface closes the gates of nerve conduction for severe pain

Correct answer: D

Rationale: The correct answer is D. TENS works by delivering a mild electrical stimulus that can block pain signals from reaching the brain, effectively reducing the perception of pain. Choice A is incorrect because TENS does not distract from pain but rather interferes with pain signals. Choice B is incorrect as TENS does not involve infusing medication into the spinal canal. Choice C is also incorrect because TENS does not target the cerebral cortex to dull pain perception but rather works at the level of nerve conduction.

4. For an older postoperative client with the nursing diagnosis 'impaired mobility related to fear of falling,' which desired outcome best directs the nurse's actions for the client?

• A. The client will ambulate with assistance every 4 hours
• B. The physical therapist will instruct the client in the use of a walker
• C. The client will use self-affirmation statements to decrease fear
• D. The nurse will place a gait belt on the client prior to ambulation

Correct answer: C

Rationale: Encouraging the client to use self-affirmation statements is the most appropriate desired outcome in this scenario. By utilizing self-affirmation statements, the client can address their fears directly and build confidence, which can ultimately lead to a reduction in fear of falling. While ambulating with assistance (choice A) is important, the focus here is on addressing the fear itself. Instructing the client in the use of a walker (choice B) and placing a gait belt on the client (choice D) are interventions that may be helpful but do not directly address the client's fear of falling.

5. A nurse is caring for a client with schizophrenia who continues to repeat the last words heard. Which nursing problem should the nurse document in the medical record?

• A. Altered thought processes
• B. Impaired social interaction
• C. Risk for self-directed violence
• D. Disturbed thought processes

Correct answer: D

Rationale: The correct answer is D: Disturbed thought processes. Echolalia, or the repetition of words, is indicative of disturbed thought processes, a common symptom in clients with schizophrenia. Choice A (Altered thought processes) is a more appropriate term than 'Disturbed thought processes' to describe the issue of echolalia. Choice B (Impaired social interaction) is not the best option in this scenario as echolalia is not primarily a social interaction issue. Choice C (Risk for self-directed violence) is not directly related to the symptom described in the question, which is echolalia, indicating a disturbance in thought processes.

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