Nursing Elites

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

• A. a full-body assessment is not specific to nail and foot care.
• B. the essential lab work of the client is not related to nail and foot assessments.
• C. the nail beds and the tissue surrounding the nails.
• D. foot corns and calluses only neglect other important aspects of nail and foot care.

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 a client's postoperative pain seems to be getting worse due to grief over the recent death of their spouse, what should the nurse consider?

• A. calling the physician for an increased dosage of pain medication
• B. calling the physician for a sedative
• C. referring the client for a psychiatric consult
• D. developing interventions for grief and loss

Correct answer: D

Rationale: The correct answer is developing interventions for grief and loss. In this scenario, the client's pain is not solely sensory but also affective due to grieving over the death of their spouse. It is essential to address the emotional component of pain by providing support and interventions for grief and loss. Referring the client for a psychiatric consult may not be necessary as grieving is a normal response to such a significant loss. Calling the physician for an increased dosage of pain medication or a sedative solely focuses on the sensory aspect of pain and does not address the underlying emotional distress.

3. A primigravida begins labor when her family is unavailable and she is alone. She is very upset that her family is not with her. Which approach can the nurse take to meet the client's needs at this time?

• A. asking whether another individual wants to be her support person
• B. assuring her that a nursing staff member will be with her at all times
• C. telling her you will try to locate her family
• D. reinforcing the woman's confidence in her own abilities to cope and maintain a sense of control

Correct answer: A

Rationale: In this situation, the best approach for the nurse is to ask whether another individual wants to be the client's support person. This empowers the client to choose someone to be with her until her family can join her, providing the needed support and comfort. Assuring her that a nursing staff member will be with her at all times (Choice B) may not fully address her emotional needs for familiar support. Telling her you will try to locate her family (Choice C) may not be feasible in the immediate situation and may not provide immediate emotional support. While reinforcing the woman's confidence in her own abilities (Choice D) is important, it may not fully address her current need for emotional support and presence of a companion.

4. A client scheduled for surgery tells the nurse that he signed an informed consent for the surgical procedure but was never told about the risks of the surgery. The nurse serves as the client's advocate by undertaking which action?

• A. Reassuring the client that the risks are minimal
• B. Noting in the client's record that the client was not told about the risks of the surgery
• C. Writing a note on the front of the client's record so that the surgeon will see it when the client arrives in the operating room
• D. Informing the surgeon verbally about the lack of information provided to the client

Correct answer: B

Rationale: A nurse serves as a client advocate by protecting the client's right to be informed and to participate in decisions regarding care. In this scenario, the nurse should document in the client's record that the client was not informed about the risks of the surgery. This action ensures that the issue is officially noted and can be addressed by the healthcare team. Reassuring the client that the risks are minimal is incorrect because it dismisses the client's concerns and does not address the lack of information provided. Writing a note on the client's chart to inform the surgeon is not as effective as ensuring that the issue is officially documented in the client's record, where it can be reviewed and addressed by the healthcare team. Informing the surgeon verbally is not as reliable as documenting the concern in the client's record, which provides a formal and lasting record for review and follow-up.

5. A new mother asks the nurse, 'I was told that my infant received my antibodies during pregnancy. Does that mean that my infant is protected against infections?' Which statement should the nurse make in response to the mother?

• A. The immune system of an infant is immature, and the infant is at risk for infection.
• B. The transfer of your antibodies protects your infant until the infant is 12 months old.
• C. Yes, your infant is protected from all infections.
• D. If you breastfeed, your infant is protected from infection.

Correct answer: A

Rationale: The transplacental transfer of maternal antibodies supplements the infant's weak response to infection until approximately 3 to 4 months of age. While the infant starts producing immunoglobulin (Ig) soon after birth, it only reaches about 60% of the adult IgG level, 75% of the adult IgM level, and 20% of the adult IgA level by 1 year of age. Breast milk provides additional IgA protection. Although the immune system matures during infancy, full protection against infections is not achieved until early childhood, putting the infant at risk for infections. Choice B is incorrect because maternal antibody protection typically lasts around 3 to 4 months, not until the infant is 12 months old. Choice C is incorrect as infants are not shielded from all infections due to their immature immune system. Choice D is incorrect because while breastfeeding offers extra protection, it does not guarantee complete immunity against infections.

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