Nursing Elites

1. Nurses caring for clients who have cancer and are taking opioids need to assess for all of the following except:

• A. tolerance.
• B. constipation.
• C. sedation.
• D. addiction.

Correct answer: D

Rationale: The correct answer is 'addiction.' When caring for clients with cancer who are taking opioids, nurses need to assess for tolerance, constipation, and sedation as these are common side effects of opioid use. Addiction is not a primary concern when managing pain in terminally ill clients, as the goal is effective pain management rather than addiction prevention. Tolerance refers to the body's adaptation to the opioid over time, requiring higher doses for the same effect. Constipation and sedation are common side effects of opioids that nurses need to monitor and manage. Addiction is not a major concern in this population as the focus is on providing comfort and pain relief.

2. The LPN is preparing a client for discharge, and the discharge medications include phenobarbital. Which of these client statements would indicate a need for reinforced teaching about this medication?

• A. "I will need to avoid eating excessive leafy greens."?
• B. "It's best to take this medication with food."?
• C. "I can't wait to get back to my nightly glass of wine."?
• D. "I should try to take this medication at the same time every day."?

Correct answer: C

Rationale: The correct answer is, "I can't wait to get back to my nightly glass of wine,"? as phenobarbital should not be taken with alcohol as it is a barbiturate. Alcohol may increase the sedative effect, posing risks to the patient's safety. Choice A, "I will need to avoid eating excessive leafy greens,"? is unrelated to phenobarbital and not a cause for reinforced teaching. Choice B, "It's best to take this medication with food,"? is a general instruction and not specific to phenobarbital. Choice D, "I should try to take this medication at the same time every day,"? is a common recommendation for medication adherence but does not highlight a specific concern related to phenobarbital.

3. During data collection of a client with suspected carpal tunnel syndrome, a nurse plans to perform the Phalen test. The nurse should ask the client to perform which activity?

• A. Dorsiflex the foot
• B. Plantarflex the foot
• C. Hold the hands back to back while flexing the wrists 90 degrees for 60 seconds
• D. Hyperextend the fingers with the palmar surfaces of the hands touching, holding the position for 60 seconds

Correct answer: C

Rationale: In the Phalen test, the nurse asks the client to hold the hands back to back while flexing the wrists 90 degrees. This position puts pressure on the median nerve, eliciting symptoms in carpal tunnel syndrome. Dorsiflexing or plantarflexing the foot and hyperextending the fingers are not associated with testing for carpal tunnel syndrome. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand.

4. The goals of palliative care include all of the following except:

• A. giving clients with life-threatening illnesses the best quality of life possible
• B. taking care of the whole person"?body, mind, spirit, heart, and soul
• C. no interventions are needed because the client is near death
• D. supporting the needs of the family and client

Correct answer: C

Rationale: The goals of palliative care include choices A, B, and D. Choice C, 'no interventions are needed because the client is near death,' is not part of palliative care. Palliative care involves giving clients with life-threatening illnesses the best quality of life possible, taking care of the whole person"?body, mind, spirit, heart, and soul, and supporting the needs of the family and client. Interventions are crucial in palliative care to ensure the comfort and well-being of the client until the end of life. Therefore, the correct answer is that no interventions are needed because the client is near death.

5. At a health screening clinic, a nurse is educating a young woman about breast self-examination (BSE). The nurse determines that the client demonstrates understanding when she makes which statement?

• A. BSE should be performed monthly after the menstrual period.
• B. BSE is performed after the menstrual period.
• C. Monthly BSE is a recommended method for early detection of breast cancer.
• D. Monthly BSE includes inspection before a mirror and palpation both in the shower and while lying down.

Correct answer: D

Rationale: The correct answer is 'Monthly BSE includes inspection before a mirror and palpation both in the shower and while lying down.' BSE should be performed monthly after the menstrual period, not every other month or on the day menstruation begins. Performing BSE on the seventh day of the menstrual cycle when the breasts are smallest and least congested is recommended. While BSE is a useful tool for early detection, it is not the only method. Regular physical examinations and mammograms are also important. The correct technique for BSE includes inspecting the breasts in front of a mirror, palpating in the shower for easier detection, and conducting palpation while lying down for thorough examination.

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