Nursing Elites

1. The healthcare professional caring for a patient who is immobile frequently checks for impaired skin integrity. What is the rationale for this action?

• A. Inadequate blood flow leads to decreased tissue ischemia.
• B. Patients with limited caloric intake develop thicker skin.
• C. Pressure reduces circulation to affected tissue.
• D. Verbalization of skin care needs is decreased.

Correct answer: C

Rationale: The rationale behind checking for impaired skin integrity in an immobile patient is that pressure reduces circulation to the affected tissue. Prolonged pressure on specific body parts can lead to reduced blood flow to those areas, causing tissue damage and potentially leading to pressure ulcers. Choices A, B, and D are incorrect because inadequate blood flow causing decreased tissue ischemia, limited caloric intake leading to thicker skin, and decreased verbalization of skin care needs are not directly related to the rationale for checking for impaired skin integrity in immobile patients.

2. A male client presents to the clinic stating that he has a high-stress job and is having difficulty falling asleep at night. The client reports having a constant headache and is seeking medication to help with sleep. Which intervention should the nurse implement?

• A. Determine the client's sleep and activity patterns
• B. Obtain a prescription for the client to take when stressed
• C. Refer the client for a sleep study and neurological follow-up
• D. Teach coping strategies to use when feeling stressed

Correct answer: A

Rationale: Assessing the client's sleep and activity patterns is crucial in understanding the factors contributing to the sleep difficulties and headaches. By evaluating these patterns, the nurse can identify triggers, stressors, and lifestyle habits that may be impacting the client's sleep quality and overall well-being. This assessment will guide the nurse in formulating an appropriate care plan tailored to the client's specific needs. Option B is not appropriate as it focuses solely on providing medication without addressing underlying issues. Option C is premature as a thorough assessment should precede any referrals for specialized studies. Option D, while important, should come after understanding the client's sleep patterns to provide more targeted coping strategies.

3. The LPN/LVN observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first?

• A. Observe the appearance of the skin under the ice pack.
• B. Instruct the client regarding the importance of the covering.
• C. Reapply the covering after filling it with fresh ice.
• D. Ask the client how long the ice pack was applied to the skin.

Correct answer: A

Rationale: The correct first action for the nurse to take when a client removes the covering from an ice pack is to observe the appearance of the skin under the ice pack. This assessment is crucial to check for any skin damage or adverse reactions resulting from direct contact with the ice pack. Instructing the client about the importance of the covering (Choice B) can follow the skin assessment. Reapplying the covering (Choice C) before skin assessment may potentially cause harm. Asking the client about the duration of ice application (Choice D) is not the immediate priority; ensuring skin integrity is the primary concern.

4. A healthcare professional is preparing to assess a patient for orthostatic hypotension. Which piece of equipment will the professional obtain to assess for this condition?

• A. Thermometer
• B. Elastic stockings
• C. Blood pressure cuff
• D. Sequential compression devices

Correct answer: C

Rationale: To assess for orthostatic hypotension, a healthcare professional needs to obtain a blood pressure cuff. Orthostatic hypotension is defined as a drop in blood pressure greater than 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure when moving from lying down to a standing position. A thermometer (Choice A) is used to measure body temperature and is not directly related to assessing orthostatic hypotension. Elastic stockings (Choice B) are used for preventing deep vein thrombosis and improving circulation in the lower extremities, not for assessing orthostatic hypotension. Sequential compression devices (Choice D) are mechanical pumps that are used to prevent deep vein thrombosis and are not specifically used for assessing orthostatic hypotension.

5. A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on clients who are confused. Which of the following instructions should the nurse include?

• A. “Use full-length side rails on the client’s bed.”
• B. “Check on the client frequently while they are in the restroom.”
• C. “Encourage physical activity throughout the day to expend energy.”
• D. “Remove clocks from the client’s room.”

Correct answer: C

Rationale: Encouraging physical activity is an effective non-restraint intervention for managing confused clients. It helps reduce agitation, promotes circulation, and may decrease the need for restraints. Choice A is incorrect as using full-length side rails can potentially restrict a client's movement, which is counterproductive to avoiding restraints. Choice B, while emphasizing monitoring, does not directly address alternatives to restraint use. Choice D is also incorrect as removing clocks from the client's room does not directly address managing confusion and reducing the need for restraints.

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