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 nurse helps a young adult conduct a personal lifestyle assessment. The nurse carefully reviews the assessment with the young adult for which reason?

• A. Young adults may ignore physical symptoms and postpone seeking health care
• B. Young adults are unable to afford health insurance
• C. Young adults are at risk for a serious illness
• D. Young adults are exposed to hazardous substances

Correct answer: A

Rationale: The corrected answer is A: Young adults may ignore physical symptoms and postpone seeking health care. Young adults are usually quite active, experience severe illnesses less commonly than members of older age groups, tend to ignore physical symptoms, and often postpone seeking health care. Clients in this developmental stage may benefit from a personal lifestyle assessment to identify habits that increase the risk for various chronic diseases. Choice B is incorrect because the ability to afford health insurance is not the primary reason for conducting a personal lifestyle assessment. Choice C is incorrect because young adults are not inherently at higher risk for serious illness compared to other age groups. Choice D is incorrect because exposure to hazardous substances is not the main focus when conducting a personal lifestyle assessment.

3. A woman in labor whose cervix is not completely dilated is pushing strenuously during contractions. Which method of breathing should the nurse encourage the woman to perform to help her overcome the urge to push?

• A. Holding her breath and using the Valsalva maneuver
• B. Blowing repeatedly in short puffs
• C. Cleansing breaths
• D. Deep inspiration and expiration at the beginning and end, respectively, of each contraction

Correct answer: B

Rationale: If a woman pushes strenuously before the cervix is completely dilated, she risks injury to the cervix and the fetal head. Blowing prevents closure of the glottis and breath-holding, helping overcome the urge to push strenuously. The woman would be encouraged to blow repeatedly, using short puffs, when the urge to push is strong. This breathing technique allows for controlled exhalation and helps prevent unnecessary pushing. Cleansing breaths (deep inspiration and expiration at the beginning and end of each contraction) are encouraged during the first stage of labor to provide oxygenation and reduce myometrial hypoxia and to promote relaxation. Holding her breath and using the Valsalva maneuver (choice A) is not recommended as it can increase intra-abdominal pressure and decrease venous return, potentially compromising fetal oxygenation. Deep inspiration and expiration at the beginning and end of each contraction (choice D) are more suitable for relaxation and oxygenation purposes rather than managing the urge to push.

4. What causes an older female client's hair to turn gray?

• A. ''A loss of melanin occurs in the normal aging process.''
• B. ''The number of sweat glands and blood vessels decreases in the normal aging process.''
• C. ''The skin on the scalp becomes thin, causing moisture to escape.''
• D. ''It is caused by hereditary factors.''

Correct answer: A

Rationale: The correct answer is 'A loss of melanin occurs in the normal aging process.' Graying hair in older adults is primarily due to a decrease in the number of melanocytes responsible for providing pigment and hair color. This reduction in melanin production leads to gray hair. The other choices are incorrect. While it is true that the skin becomes thinner with aging and the number of sweat glands and blood vessels decreases, these changes are not directly related to graying hair. Additionally, hereditary factors can influence when graying starts, but they do not cause the graying of hair itself.

5. When a client who is having trouble conceiving says to the nurse, 'I have started taking ginseng,' the best response by the nurse is:

• A. "There is some evidence that ginseng may enhance in vitro sperm motility."?
• B. "Some studies show that ginseng enhances in vitro sperm motility."?
• C. "Ginseng is not proven to be effective for infertility; have you considered other options?"?
• D. "It's probably not going to hurt you, but it's also probably not going to help. Let's look at some other alternatives."?

Correct answer: B

Rationale: Some studies have shown that ginseng enhances in vitro sperm motility, making Choice B the correct response. It directly addresses the client's comments about taking ginseng and provides valuable information regarding its potential effect on sperm motility. Alternative therapies are often sought by couples struggling with infertility, and acknowledging the potential benefits of ginseng can empower the client. Choice A is incorrect as it slightly misrepresents the evidence by overgeneralizing its effectiveness. Choice C dismisses ginseng without acknowledging its potential benefits, potentially closing off a fruitful discussion with the client. Choice D, while neutral, misses the opportunity to validate the client's choice and explore further options collaboratively. It is crucial for nurses to respect clients' choices, provide accurate information, and guide them effectively in exploring different alternatives.

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