Nursing Elites

1. The nurse is assessing an older adult client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding?

• A. Ptosis on the left eyelid.
• B. Nystagmus.
• C. Astigmatism.
• D. Exophthalmos.

Correct answer: A

Rationale: The correct answer is A: 'Ptosis on the left eyelid.' Ptosis is the term used to describe an eyelid droop that covers a large portion of the iris, which may be caused by issues with the oculomotor nerve or eyelid muscles. Choice B, 'Nystagmus,' refers to involuntary eye movements and is not related to eyelid drooping. Choice C, 'Astigmatism,' is a refractive error affecting vision due to an irregularly shaped cornea or lens, not an eyelid condition. Choice D, 'Exophthalmos,' is a protrusion of the eyeball associated with conditions like hyperthyroidism, not eyelid drooping.

2. The nurse is teaching a group of high school adolescents about safety associated with traumatic injuries. Which factor causing spinal cord injuries should the nurse discuss with the adolescents?

• A. motor vehicle accidents
• B. violent assault
• C. sports injuries
• D. falls

Correct answer: A

Rationale: The correct answer is A: motor vehicle accidents. Motor vehicle accidents are a significant cause of spinal cord injuries among adolescents due to the high impact forces involved. While violent assault, sports injuries, and falls can also lead to spinal cord injuries, statistics show that motor vehicle accidents are a leading cause in this age group. Educating adolescents about the risks and preventive measures related to motor vehicle accidents is crucial in promoting their safety and well-being.

3. After coronary artery bypass graft surgery, a male client is admitted to the coronary care unit. Which nursing diagnosis is of the highest priority?

• A. Ineffective breathing pattern.
• B. Impaired gas exchange.
• C. Acute pain.
• D. Risk for infection.

Correct answer: B

Rationale: Impaired gas exchange is the highest priority nursing diagnosis because it directly impacts the client's oxygenation. Following coronary artery bypass graft surgery, ensuring adequate oxygen exchange is crucial for the client's recovery. Ineffective breathing pattern, although important, may not be as critical as impaired gas exchange in the immediate postoperative period. Acute pain, while significant, can be managed effectively with appropriate interventions and is not as emergent as addressing impaired gas exchange. Risk for infection is also a valid concern post-surgery, but ensuring optimal gas exchange takes precedence to prevent complications associated with inadequate oxygenation.

4. A nurse has started a group for senior citizens in a church setting. The group decides that their first project will be to begin a program for home-bound members. Which program outcome is the best measure of the project's effectiveness?

• A. number of home-bound seniors who are visited
• B. number of church members who are over 65
• C. average annual income for the homebound members
• D. calls received showing interest in the program

Correct answer: A

Rationale: The number of home-bound seniors visited is the best measure of the project's effectiveness as it directly reflects the reach and impact of the program. Choice B is incorrect as it does not directly relate to the effectiveness of the program for home-bound seniors. Choice C is irrelevant as the average annual income of home-bound members is not a direct measure of the program's effectiveness. Choice D, calls showing interest, is not as direct a measure as the actual visits to the home-bound seniors.

5. The parish nurse notes that an elderly male client has had a 5 lbs weight loss since his check-up one month ago. The client has good hygiene, still drives a car, and lives alone. To which agency should the nurse refer this client?

• A. the adult day care center
• B. the social security administration office
• C. the women, infants, and children office
• D. the senior citizen center

Correct answer: D

Rationale: The correct answer is 'D: the senior citizen center.' In this scenario, the elderly male client is experiencing unexplained weight loss, which could be indicative of underlying health issues or social isolation. Referring him to the senior citizen center is appropriate as it can provide social support, resources, and programs tailored to address the client's weight loss and overall well-being. Choice A, the adult day care center, is not the most suitable option as the client is still independent and living alone. Choice B, the social security administration office, and Choice C, the women, infants, and children office, are not relevant in this context and do not address the client's specific needs related to weight loss and social support.

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