Nursing Elites

1. The nurse is caring for a client with cerebral palsy. The nurse should provide frequent rest periods because:

• A. Grimacing and writhing movements decrease with relaxation and rest.
• B. Hypoactive deep tendon reflexes become more active with rest.
• C. Stretch reflexes are increased with rest.
• D. Fine motor movements are improved.

Correct answer: A

Rationale: Frequent rest periods help to relax tense muscles and preserve energy in clients with cerebral palsy. This can lead to a decrease in grimacing and writhing movements, as relaxation and rest help to alleviate muscle tension. Choices B, C, and D are incorrect because they provide inaccurate information. Hypoactive deep tendon reflexes do not become more active with rest; stretch reflexes are not increased with rest in cerebral palsy patients, and fine motor movements are not necessarily improved solely by rest.

2. A client who recently lost 50 pounds just received news that she is pregnant. A possible nursing diagnosis is:

• A. Actual Chronic Low Self-Esteem (related to obesity).
• B. Potential Chronic Low Self-Esteem (related to obesity).
• C. Actual Situational Low Self-Esteem (related to fear of weight regain and pregnancy).
• D. Potential Situational Low Self-Esteem (related to fear of weight regain and pregnancy).

Correct answer: D

Rationale: In this scenario, the client's recent weight loss and subsequent pregnancy could lead to concerns about weight regain and body image. The most appropriate nursing diagnosis is 'Potential Situational Low Self-Esteem (related to fear of weight regain and pregnancy).' This diagnosis reflects the client's potential emotional response to the fear of losing the progress achieved through weight loss and dealing with changes in body image due to pregnancy. Options A and C imply that low self-esteem is already present, which is not supported by the information given. Option B is not as suitable as the client's self-esteem issues are more related to the fear of weight regain and pregnancy, making option D the best choice.

3. After a client undergoes a left lower lobe lung resection for lung cancer, which post-operative measure would typically be included in the plan?

• A. Closed chest drainage
• B. A tracheostomy
• C. A mediastinal tube
• D. Percussion vibration and drainage

Correct answer: A

Rationale: After a lung resection, such as the removal of the left lower lobe for lung cancer, closed chest drainage is a common post-operative measure to help drain any excess air or fluid from the chest cavity. A tracheostomy is not typically needed for this procedure, so choice B is incorrect. Similarly, a mediastinal tube is not routinely inserted following a left lower lobe lung resection, making choice C incorrect. Percussion vibration and drainage are not indicated for this type of surgery, so choice D is also incorrect. Therefore, the correct answer is closed chest drainage.

4. A client is admitted with Ewing's sarcoma. Which symptoms would be expected due to this tumor's location?

• A. Hemiplegia
• B. Aphasia
• C. Nausea
• D. Bone pain

Correct answer: D

Rationale: Ewing's sarcoma is a type of bone cancer that primarily affects the bones. Therefore, bone pain would be an expected symptom due to this tumor's location. Hemiplegia, which refers to paralysis on one side of the body, Aphasia, a language disorder, and Nausea are not typical symptoms of Ewing's sarcoma. While Nausea is a common symptom in various conditions, it is not specific to bone cancer like Ewing's sarcoma. Therefore, Bone pain is the most likely symptom associated with Ewing's sarcoma.

5. Social support systems include all of the following except:

• A. call-in help lines
• B. emotional assistance provided by others
• C. community support groups
• D. use of coping skills and verbalization for anger management

Correct answer: D

Rationale: Social support systems involve external sources of support like call-in help lines, emotional assistance from others, and community support groups. These external resources provide individuals with assistance and comfort. Coping skills and verbalization for anger management are personal strategies that individuals use to manage emotions internally. While these skills can be beneficial, they are not considered part of external social support systems.

Similar Questions