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. Which of the following clients requires airborne precautions?

• A. a client with fever, chills, vomiting, and diarrhea
• B. a client suspected of varicella (chickenpox)
• C. a client with abdominal pain and purpura
• D. a client diagnosed with AIDS

Correct answer: B

Rationale: The correct answer is 'a client suspected of varicella (chickenpox).' Chickenpox is an acute, infectious airborne illness that requires airborne precautions, including wearing a respirator mask for direct contact with the patient. Choices A, C, and D do not typically require airborne precautions. Choice A describes symptoms that may indicate a gastrointestinal infection but do not require airborne precautions. Choice C mentions abdominal pain and purpura, which are not specific to an airborne illness. Choice D, a client diagnosed with AIDS, does not necessitate airborne precautions unless there are additional infectious conditions present that require such measures.

3. When a 17-year-old client arrives at the clinic suspecting a sexually transmitted infection, what information does the nurse provide concerning informed consent?

• A. She will need to sign an informed consent form.
• B. Her mother or father will need to be contacted for permission to treat her.
• C. A consent form is not needed if the problem is a sexually transmitted infection.
• D. Anyone over the age of 18 years may sign a consent form for her treatment.

Correct answer: A

Rationale: Informed consent is a person's agreement to allow something, such as a treatment, to be performed. A consent form is required even if the problem is a sexually transmitted infection. If the client is a minor, the minor may sign the informed consent form in specific situations, including seeking treatment for a sexually transmitted infection. In this case, the 17-year-old client is seeking examination and treatment for a sexually transmitted infection, so she will need to sign the informed consent form. Contacting her parents for permission is not required in this situation. Choice C is incorrect because a consent form is necessary regardless of the medical issue. Choice D is incorrect because the individual's age is not the determining factor; rather, it is the nature of the medical service being sought that dictates the need for informed consent.

4. Which of the following might be an appropriate nursing diagnosis for an epileptic client?

• A. Dysreflexia
• B. Risk for Injury
• C. Urinary Retention
• D. Unbalanced Nutrition

Correct answer: B

Rationale: The correct nursing diagnosis for an epileptic client would be 'Risk for Injury' as the client is prone to injuries during seizure activity, such as head trauma from falls. Epilepsy does not typically cause dysreflexia. While urinary retention may occur during or after a seizure, it is not a common nursing diagnosis related to epilepsy. 'Unbalanced Nutrition' is not a priority nursing diagnosis for an epileptic client compared to the immediate risk of injury during seizures.

5. A case manager is reviewing the records of the clients in the nursing unit. Which note(s) in a client's record indicate an unexpected outcome and the need for follow-up?

• A. A client is performing their own colostomy irrigations.
• B.
• C. A client who has just undergone surgery has a urine output of more than 30 mL/hr.
• D. A client with a new diagnosis of diabetes mellitus is self-administering insulin.

Correct answer: B

Rationale:

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