Nursing Elites

1. Inspiratory and expiratory stridor may be heard in a client who:

• A. Is experiencing an exacerbation of goiter
• B. Is experiencing an acute asthmatic attack
• C. Has aspirated a piece of meat
• D. Has severe laryngotracheitis

Correct answer: D

Rationale: Inspiratory and expiratory stridor are high-pitched, wheezing sounds caused by disrupted airflow due to airway obstruction. Severe laryngotracheitis, involving inflammation and swelling of the larynx and trachea, leads to airway obstruction and can produce both inspiratory and expiratory stridor. Exacerbation of goiter, an acute asthmatic attack, and aspiration of a piece of meat are not typically associated with both inspiratory and expiratory stridor. Therefore, choices A, B, and C are incorrect.

2. Which condition is most commonly associated with a "bull's eye" rash?

• A. Lyme disease
• B. Rocky Mountain spotted fever
• C. Syphilis
• D. Toxoplasmosis

Correct answer: A

Rationale: The correct answer is A: Lyme disease. The "bull's eye" rash, or erythema migrans, is a hallmark of early Lyme disease, caused by the bacterium Borrelia burgdorferi. Choice B, Rocky Mountain spotted fever, presents with a different type of rash. Choice C, Syphilis, typically presents with a painless ulcer and rash but not a "bull's eye" rash. Choice D, Toxoplasmosis, does not typically present with a "bull's eye" rash.

3. An adult client is undergoing weekly external radiation treatments for breast cancer. Upon arrival at the outpatient clinic for a scheduled treatment, the client reports increasing fatigue to the PN who is taking the client's vital signs. What action should the PN implement?

• A. Notify the healthcare provider or charge nurse immediately
• B. Offer to reschedule the treatment for the following week
• C. Plan to monitor the client's vital signs every 30 minutes
• D. Reinforce the need for extra rest periods and plenty of sleep

Correct answer: D

Rationale: When a client undergoing radiation therapy reports increasing fatigue, it is essential to address this common side effect. Educating the client on the importance of rest and sleep can help manage fatigue and promote recovery. Contacting the healthcare provider or charge nurse immediately may not be necessary unless fatigue is severe and other symptoms are present. Rescheduling the treatment or monitoring vital signs more frequently is not the priority in this situation.

4. The PN is caring for a client who had an acute brain attack with resulting expressive aphasia and urinary incontinence. To ensure care for the client, which task should the PN delegate to the UAP?

• A. Explain how to use a communication board
• B. Document progress in the use of the communication board
• C. Encourage voiding by assisting the client to the bedside commode
• D. Establish a bladder training schedule and methods

Correct answer: C

Rationale: Assisting the client to the bedside commode is an appropriate task for the UAP as it involves basic patient care and mobility assistance, which are within the UAP's scope of practice. Options A and B involve communication techniques and documentation, which are more appropriate for licensed nursing staff. Option D involves establishing a bladder training schedule, which requires assessment and planning skills beyond the UAP's role.

5. How does the home care nurse determine that a 78-year-old client is unable to remain in his current residence alone?

• A. The goals set by the client
• B. The learning level of the client
• C. Assessing the home environment
• D. The distractions in the client's home

Correct answer: C

Rationale: The correct answer is assessing the home environment. This process is vital in evaluating whether an elderly client can safely live independently. Factors like safety hazards and the client's ability to handle daily activities are considered during this assessment. Choices A, B, and D are incorrect because determining the client's ability to remain in his residence alone relies more on evaluating the home environment for safety and suitability rather than the client's goals, learning level, or distractions in the home.

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