Nursing Elites

1. The home health PN suspects elder abuse after observing fresh lacerations on the arms and legs of an older adult male client who lives with his daughter. Which action is most important for the PN to take?

• A. Document the lacerations in the client's record
• B. Report findings to the supervisor for referral to adult protective services
• C. Ask the daughter who has been taking care of the client on a daily basis
• D. Apply dry dressings after cleansing the wounds

Correct answer: B

Rationale: The most important action for the PN to take in this situation is to report the findings to the supervisor for referral to adult protective services. Suspected elder abuse must be reported promptly to ensure the safety and protection of the client. Documenting the lacerations in the client's record is important but not as critical as reporting the suspected abuse. Asking the daughter who is the potential abuser may not yield accurate information and could compromise the safety of the client. Applying dressings to the wounds is a lower priority compared to addressing the suspected elder abuse.

2. The PN and UAP enter a client's room and find the client lying on the bed. The PN determines that the client is unresponsive. Which instruction should the PN give the UAP first?

• A. Obtain emergency help
• B. Feel for a carotid pulse
• C. Bring a glucometer to the room
• D. Check the blood pressure

Correct answer: A

Rationale: The correct answer is to instruct the UAP to obtain emergency help first. When a client is unresponsive, it could indicate a life-threatening condition that requires immediate intervention. Ensuring emergency help is on the way is the priority to address the potentially critical situation. Feeling for a carotid pulse, bringing a glucometer, or checking the blood pressure are important assessments but should come after taking steps to secure immediate assistance.

3. What is the primary purpose of performing range-of-motion (ROM) exercises?

• A. To improve cardiovascular fitness
• B. To prevent muscle atrophy and joint contractures
• C. To increase respiratory function
• D. To enhance cognitive function

Correct answer: B

Rationale: The primary purpose of performing range-of-motion (ROM) exercises is to prevent muscle atrophy and joint contractures. These exercises are crucial in maintaining joint mobility and muscle flexibility, especially in patients who are immobilized or have limited mobility. Improving cardiovascular fitness (Choice A) involves different types of exercises that target the heart and blood vessels, not specifically ROM exercises. Increasing respiratory function (Choice C) is typically achieved through breathing exercises and activities that enhance lung capacity. Enhancing cognitive function (Choice D) is usually addressed through cognitive exercises and activities that stimulate brain function.

4. While providing oral care for a client who is unconscious, the nurse positions the client laterally and uses a basin to collect secretions. Which intervention is best for the nurse to implement?

• A. Swab the oral cavity with a washcloth
• B. Use oral swabs with normal saline
• C. Provide a Yankauer tip for oral suction
• D. Support the head with a small pillow

Correct answer: B

Rationale: Using oral swabs with normal saline is the best intervention in this scenario as it effectively cleans the oral cavity without causing irritation or dryness, which is crucial for an unconscious client. Swabbing the oral cavity with a washcloth may not provide thorough cleaning, and it can potentially cause irritation. Providing a Yankauer tip for oral suction is not necessary unless there are excessive secretions that need to be suctioned. Supporting the head with a small pillow, although important for comfort, is not directly related to oral care in an unconscious client.

5. In which condition is the 'butterfly rash' most commonly seen?

• A. Systemic lupus erythematosus
• B. Rheumatoid arthritis
• C. Psoriasis
• D. Dermatomyositis

Correct answer: A

Rationale: The correct answer is A: Systemic lupus erythematosus (SLE). The 'butterfly rash' across the cheeks and nose is a classic sign of SLE, an autoimmune disease. This rash is a key dermatological manifestation of SLE, often triggered or worsened by exposure to sunlight. Choices B, C, and D are incorrect because the 'butterfly rash' is not commonly associated with rheumatoid arthritis, psoriasis, or dermatomyositis.

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