Nursing Elites

1. The LPN has been asked to help a client taking Risperdal with activities of daily living in the morning. Which of these tasks is most likely to be potentially impacted by this medication?

• A. eating breakfast
• B. drinking fluids
• C. getting out of bed to use the bathroom
• D. brushing teeth

Correct answer: C

Rationale: The correct answer is 'getting out of bed to use the bathroom.' Risperdal can cause orthostatic hypotension, leading to a drop in blood pressure when changing positions from lying down to standing up. This effect increases the risk of falls, emphasizing the need to assist the client with this task to prevent potential harm. Choices A, B, and D are less likely to be directly impacted by the medication, unlike the significant risk of orthostatic hypotension associated with changing positions.

2. A client with peripheral artery disease tells the nurse that pain develops in his left calf when he is walking and subsides with rest. The nurse documents that the client is most likely experiencing which disorder?

• A. Venous insufficiency
• B. Intermittent claudication
• C. Sore muscles from overexertion
• D. Muscle cramps related to musculoskeletal problems

Correct answer: B

Rationale: Leg pain characteristic of peripheral artery disease is known as intermittent claudication. The client can walk only a certain distance before cramping, burning, muscle discomfort, or pain forces them to stop, with the pain subsiding after rest. The pain is reproducible, and as the disease progresses, the client can walk shorter distances before the pain recurs. Ultimately, pain may even occur at rest. Venous insufficiency (Choice A) involves impaired blood flow in the veins, leading to swelling and skin changes but not typically pain associated with exercise. Sore muscles from overexertion (Choice C) and muscle cramps related to musculoskeletal problems (Choice D) do not present with the characteristic pattern of pain associated with peripheral artery disease.

3. A nurse in a day-care setting is planning play activities for 2- and 3-year-old children. Which toys are most appropriate for these activities?

• A. Finger paints and card games
• B. Blocks and push-pull toys
• C. Videos and cutting-and-pasting toys
• D. Simple board games and puzzles

Correct answer: B

Rationale: The most appropriate toys for 2- and 3-year-old children in a day-care setting are blocks and push-pull toys. Toddlers enjoy objects of different textures like clay, sand, finger paints, and bubbles, as well as push-pull toys, large balls, and sand and water play. They also like activities such as blocks, painting, coloring with large crayons, large puzzles, and playing with trucks or dolls. Finger paints and card games may be more suitable for older children. Videos and cutting-and-pasting toys are generally more appropriate for preschoolers. Blocks and push-pull toys are beneficial for young children as they help in developing fine motor skills, hand-eye coordination, spatial awareness, and creativity. These toys also encourage imaginative play and problem-solving, making them ideal choices for toddlers.

4. A client states, "I eat a well-balanced diet. I do not smoke. I exercise regularly, and I have a yearly checkup with my physician. What else can I do to help prevent cancer?"? The nurse should respond with which of the following statements?

• A. Sleep at least 6-8 hours per night.
• B. Practice monthly self-breast examinations.
• C. Reduce stress.
• D. All of the above.

Correct answer: D

Rationale: All of the choices are methods of preventing cancer. Sleep is important in maintaining homeostasis, which helps the body respond to disease. Monthly breast examination can indicate cancer or fibrocystic disease. Stress can have a physiological response in the body that decreases the immune response and increases the risk of disease. Therefore, all the options provided are important in cancer prevention, making 'All of the above' the correct answer. Option A is crucial for overall health and immune function, option B aids in early detection, and option C is vital as chronic stress can weaken the immune system.

5. 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.

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