Nursing Elites

1. 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.

2. 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.

3. When transferring a client with hemiparesis from a bed to a wheelchair, which safety measure should be implemented?

• A. Standing the client and walking them to the wheelchair
• B. Moving the wheelchair close to the client's bed and standing and pivoting the client on their unaffected extremity to the wheelchair
• C. Moving the wheelchair close to the client's bed and standing and pivoting the client on their affected extremity to the wheelchair
• D. Having the client stand and push their body to the wheelchair

Correct answer: C

Rationale: When transferring a client with hemiparesis from a bed to a wheelchair, it is crucial to ensure their safety. The correct safety measure is to move the wheelchair close to the client's bed and have the client stand and pivot on their unaffected extremity to the wheelchair. This method provides support with the unaffected limb, reducing the risk of falls or injuries. Choice A is incorrect as it suggests walking the client, which may not be safe or feasible. Choice C is incorrect because pivoting on the affected extremity can increase the risk of injury. Choice D is incorrect as it does not consider the client's limitations and safety needs, as it involves pushing their body which may not be possible with hemiparesis.

4. While performing a physical assessment on a 6-month-old infant, the nurse observes head lag. Which of the following nursing actions should the nurse perform first?

• A. Ask the parents to allow the infant to lie on his stomach to promote muscle development.
• B. Notify the physician because a developmental or neurological evaluation is indicated.
• C. Document the findings as abnormal in the nurse's notes.
• D. Explain to the parents that their child is likely to have developmental delays.

Correct answer: B

Rationale: Head lag should be completely resolved by 4 months of age. Continuing head lag at 6 months of age indicates the need for further developmental or neurological evaluation. Laying the infant on his stomach promotes muscle development of the neck and shoulder muscles, but because of the age of this child, a referral should be the first action. The findings are abnormal for a 6-month-old infant. Significant head lag can be seen in infants with Down syndrome and hypoxia, as well as neurological and other metabolic disorders. While some of these disorders might include developmental delays, stating this to the parents without a proper evaluation can cause unnecessary distress. The priority is to identify the cause of the head lag through a medical evaluation before discussing potential outcomes with the parents.

5. At what age are yearly mammograms recommended to start?

• A. Yearly mammograms are recommended starting at age 25.
• B. Yearly mammograms are recommended starting at age 40.
• C. Yearly mammograms are not necessary unless there is a family history of breast cancer.
• D. Yearly mammograms are recommended starting at age 20 and continuing until menopause begins.

Correct answer: B

Rationale: The correct answer is B. The American Cancer Society recommends yearly mammograms starting at age 40 and continuing for as long as a woman is in good health. Clinical breast examination should be done about every 3 years for women in their 20s and 30s and every year for women age 40 and older. Women should know how their breasts normally look and feel and report any breast change promptly to the healthcare provider. Breast self-examination should be done monthly starting when a woman is in her 20s. Choice A is incorrect as mammograms are not recommended to start at age 25. Choice C is incorrect as yearly mammograms are still recommended even without a family history of breast cancer. Choice D is incorrect as the recommended age for starting yearly mammograms is 40, not 20.

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