Nursing Elites

1. The LPN notices a client with poor gait and balance. She is currently being treated for hypertension, but the nurse is concerned. What should the nurse do?

• A. Add this issue to the nursing care plan and include daily gait/balance training as an intervention.
• B. Do nothing as this is unrelated to the client's hospitalization.
• C. Speak with the attending physician about the concerns and request a referral for the client to go to physical therapy.
• D. Speak with the attending physician about the concerns and request a referral to physical therapy.

Correct answer: D

Rationale: Nurses should address any concerns regarding a client's health, even if they are not directly related to the reason for hospitalization. In this case, the nurse noticing the client's poor gait and balance should communicate these concerns to the attending physician. The correct course of action is to request a referral to physical therapy, as this specialized intervention can help address the client's issues effectively. Adding gait/balance training to the care plan without professional assessment and intervention may not be appropriate. Doing nothing is not in line with providing comprehensive care, and referring the client to the hospital gym is not as effective as a referral to physical therapy for addressing gait and balance issues.

2. Under what circumstances can an individual receive medical care without giving informed consent?

• A. when the durable power of attorney for health care is not available
• B. in an emergency, life-or-death situation
• C. when the physician is not available for discussion with the client
• D. when they (clients) are not able to speak for themselves

Correct answer: B

Rationale: An individual may receive medical care without giving informed consent in an emergency, life-or-death situation. This exception allows healthcare providers to provide immediate treatment to save a person's life or prevent serious harm when time is of the essence. Choices A, C, and D are incorrect because in all other situations, informed consent is required. The durable power of attorney for health care should be involved if available, the physician should have a discussion with the client in non-life-threatening situations, and in cases where clients are unable to speak for themselves, their designated representative or responsible party should be involved in the consent process.

3. A Hispanic client brings her father to the clinic because he is becoming more forgetful. He is diagnosed with Alzheimer's disease. The woman tells the nurse that she wants to try ginkgo biloba for her father before using prescription medications. Which of the following is an appropriate response by the nurse?

• A. "It is wiser to start with a prescription."?
• B. "That herb may not be effective for your father."?
• C. "You can't expect an herb to cure Alzheimer's."?
• D. "I will let the physician know of your wishes."?

Correct answer: D

Rationale: The appropriate response is to acknowledge the client's wishes and communicate them to the physician for consideration. It is important to be culturally sensitive and respect the client's preferences. Ginkgo biloba has shown some benefits in treating dementia, so it is essential to involve the healthcare provider in the decision-making process. Choices A, B, and C are dismissive and fail to consider the client's perspective and cultural beliefs. It is crucial for healthcare professionals to engage in open communication and collaboration with clients to provide patient-centered care.

4. In a disaster situation, the nurse assessing a diabetic client on insulin assesses for all of the following except:

• A. diabetic signs and symptoms.
• B. nutritional status.
• C. bleeding problems.
• D. availability of insulin.

Correct answer: C

Rationale: In a disaster situation, when assessing a diabetic client on insulin, the nurse needs to consider various factors. Diabetic signs and symptoms, nutritional status, and availability of insulin are crucial aspects to assess for appropriate management during a crisis. However, bleeding problems are not directly related to diabetes or insulin therapy. Therefore, assessing for bleeding problems is not a priority in this context. Choice C, bleeding problems, is the correct answer as it is not typically associated with diabetes, unlike the other options provided.

5. Which of the following indicates a hazard for a client on oxygen therapy?

• A. A 'No Smoking' sign is on the door.
• B. The client is wearing a synthetic gown.
• C. Electrical equipment is grounded.
• D. Matches are removed.

Correct answer: B

Rationale: The correct answer is that the client is wearing a synthetic gown. A synthetic gown might generate sparks of static electricity, which can be a fire hazard, especially in the presence of oxygen. Clients on oxygen therapy should wear cotton gowns to minimize the risk of fire. The other options are not hazards for a client on oxygen therapy: having a 'No Smoking' sign on the door promotes safety by preventing smoking, ensuring electrical equipment is grounded reduces the risk of electrical hazards, and removing matches decreases the risk of fire hazards.

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