nail and foot care are essential in meeting basic hygiene needs of clients important assessments by the nurse in this area include
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Nursing Elites

NCLEX-PN

NCLEX PN Test Bank

1. Nail and foot care are essential in meeting the basic hygiene needs of clients. Important assessments by the nurse in this area include:

Correct answer: C

Rationale: The correct answer is to assess the nail beds and the tissue surrounding the nails. This assessment is crucial to identify abnormal discoloration, lesions, paronychia, dryness, breaks in the skin, pressure areas, or any other unusual appearances. Choice A is incorrect as a full-body assessment is broader and not specific to nail and foot care. Choice B is incorrect as lab work is not directly related to nail and foot assessments. Choice D is incorrect as it focuses only on foot corns and calluses, neglecting other important aspects of nail and foot care.

2. When managing time effectively, which of the following stimuli should the nurse respond to first?

Correct answer: D

Rationale: The correct answer is to attend to the care needs of the returning postoperative client just exiting the elevator first. In a healthcare setting, patient care should always take precedence, especially for complex or unstable clients requiring immediate assessment and care. The physician's loud verbal direction, the nursing supervisor going to a meeting, and unit staff leaving on a break are important but do not involve direct patient care. Therefore, the nurse should prioritize responding to the returning postoperative client to ensure their immediate needs are met.

3. In which of the following conditions might increased cortisol levels be found?

Correct answer: A

Rationale: Cushing's syndrome is characterized by increased cortisol levels due to the overproduction of cortisol by the adrenal glands. This excess cortisol can lead to various symptoms and complications. Addison's disease is associated with decreased cortisol levels as it results from adrenal insufficiency, making it an incorrect choice in this context. Renal failure and congestive heart failure are not typically linked to abnormal cortisol levels, further indicating that they are not the conditions where increased cortisol levels are found.

4. How many temporary teeth should the nurse expect to find in a 5-year-old client's mouth?

Correct answer: C

Rationale: A 5-year-old child can have up to 20 temporary (deciduous or baby) teeth. The first tooth usually erupts by age 6 months, and the last by age 30 months. All temporary teeth are usually shed between 6 and 13 years of age. Therefore, a 5-year-old child should have up to 20 temporary teeth. The correct answer is 'up to 20.' Choices A, B, and D are incorrect because the correct number of temporary teeth in a 5-year-old child's mouth is up to 20, not 10, 15, or 32.

5. In a community hospital, a nurse is employed as a staff nurse and is supervised by a nurse manager. The nurse understands that in this position, the term authority most appropriately refers to which description?

Correct answer: B

Rationale: The term authority refers to the official power of an individual to approve or command an action or to ensure that a decision is enforced. In the context of the nurse's position supervised by a nurse manager, having authority means having the official power to ensure that organizational decisions are carried out. Choice A, accepting responsibility for the actions of others, is more related to accountability rather than authority. Choice C, bearing the legal responsibility for others' performance of tasks, is more about legal liability rather than authority. Choice D, taking responsibility for what staff members do, is similar to choice A and is more about accountability rather than having the official power to enforce decisions. Therefore, the correct answer is B as it directly relates to the concept of authority in the context described.

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