Nursing Elites

1. The client is scheduled for surgical repair of a detached retina. What is the most likely preoperative nursing diagnosis for this client?

• A. Anxiety related to loss of vision and potential failure to regain vision.
• B. Deficient knowledge (preoperative and postoperative activities) related to lack of information.
• C. Acute pain related to tissue injury and decreased circulation to the eye.
• D. Risk for infection related to the eye injury.

Correct answer: A

Rationale: The correct preoperative nursing diagnosis for a client scheduled for surgical repair of a detached retina is 'Anxiety related to loss of vision and potential failure to regain vision.' A client facing the threat of permanent blindness due to a detached retina is likely to experience anxiety. Addressing this anxiety is crucial before providing education, as severe anxiety can hinder the client's ability to absorb new information. The nurse should offer emotional support, encourage the client to express concerns, and clarify any misconceptions. Acute pain is not a typical symptom of a detached retina, and the risk of infection preoperatively is minimal, making choices C and D less relevant in this scenario.

2. Which of the following food selections would need to be removed from a tray for a client recovering from thyroidectomy?

• A. Fresh apple
• B. V8 juice
• C. Mustard greens
• D. Ice cream

Correct answer: A

Rationale: The correct answer is a fresh apple. After a thyroidectomy, it is important to avoid hard and crunchy foods like apples due to the proximity of the esophagus to the surgical site. Apples can be difficult to chew and swallow, posing a risk of injury or discomfort to the patient. V8 juice, mustard greens, and ice cream are softer options that would be more suitable for a client recovering from thyroidectomy.

3. In conducting a community health fair for a group of middle-aged citizens, which statement should the nurse emphasize in reducing the risk of coronary heart disease?

• A. Participate in at least 30 minutes of moderate physical activity 3 to 5 days per week.
• B. Engage in an aerobic exercise class every day.
• C. Limit your alcohol intake to a moderate level.
• D. The best way to lose weight is to follow a balanced diet.

Correct answer: B

Rationale: Engaging in an aerobic exercise class every day is crucial in reducing the risk of coronary heart disease. Aerobic exercises help keep the heart in shape, lower blood pressure, and improve cholesterol levels. It is recommended to participate in at least 150 minutes of moderate-intensity aerobic exercise per week, which can be achieved by engaging in aerobic exercise daily. Choice A has been corrected to emphasize the frequency required to significantly reduce the risk of coronary heart disease. Choice C has been modified to suggest moderation in alcohol intake, as excessive alcohol consumption is harmful. Choice D is also incorrect as a balanced diet, not specifically high-protein, high-fat, is recommended to reduce the risk of coronary heart disease and maintain a healthy weight.

4. Why must the nurse be careful not to cut through or disrupt any tears, holes, bloodstains, or dirt present on the clothing of a client who has experienced trauma?

• A. The clothing is the property of another and must be treated with care.
• B. Such care facilitates repair and salvage of the clothing.
• C. The clothing of a trauma victim is potential evidence with legal implications.
• D. Such care decreases trauma to the family members receiving the clothing.

Correct answer: C

Rationale: The correct answer is C. Trauma in any client, living or dead, has potential legal and/or forensic implications. Clothing, patterns of stains, and debris are sources of potential evidence and must be preserved. Nurses must be aware of state and local regulations that require mandatory reporting of cases of suspected child and elder abuse, accidental death, and suicide. Each Emergency Department has written policies and procedures to assist nurses and other health care providers in making appropriate reports. Physical evidence is real, tangible, or latent matter that can be visualized, measured, or analyzed. Emergency Department nurses can be called on to collect evidence. Health care facilities have policies governing the collection of forensic evidence. The chain of evidence custody must be followed to ensure the integrity and credibility of the evidence. The chain of evidence custody is the pathway that evidence follows from the time it is collected until it has served its purpose in the legal investigation of an incident. Choices A, B, and D are incorrect because they do not address the crucial aspect of preserving potential evidence with legal implications that may be present on the clothing of a trauma victim.

5. A 13-year-old girl is admitted to the ER with lower right abdominal discomfort. What should the admitting nurse do first?

• A. Administer Loritab to the patient for pain relief.
• B. Place the patient in a right sidelying position for pressure relief.
• C. Start a Central Line.
• D. Provide pain reduction techniques without administering medication.

Correct answer: D

Rationale: In a case of lower right abdominal discomfort, the first step should be to provide pain reduction techniques without administering medication. Administering pain medication or starting a central line should not be done without medical orders. Placing the patient in a right sidelying position may help with pressure relief, but addressing pain reduction techniques without medication is the initial priority in this scenario. It is essential to assess the patient further, consult with a healthcare provider, and follow the appropriate protocols before administering any medication or invasive procedures like starting a central line.

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