Nursing Elites

1. When caring for an elderly client and providing education, which of the following would be the least appropriate for the nurse to do?

• A. The nurse speaks loudly.
• B. The nurse allows additional time after each instruction to allow the client to process.
• C. The nurse provides supplemental written resources.
• D. The nurse breaks up the education into multiple shorter sessions.

Correct answer: A

Rationale: Speaking loudly is inappropriate when caring for an elderly client. It is essential to assess the client for a hearing impairment and provide appropriate assistance if needed. Elderly clients may require more time to process information due to slower reaction times, benefit from shorter sessions as they fatigue easily, and can absorb supplemental written resources effectively. Therefore, speaking loudly may not be conducive to effective communication and may not cater to the specific needs of the elderly client, unlike the other options provided.

2. A new mother is being discharged from the maternity unit and provided with information about signs and symptoms to report to her health care provider. Which statement by the mother indicates a need for further information?

• A. ''I will call my nurse-midwife if I experience any redness, swelling, or tenderness in my legs.''
• B. ''My temperature needs to remain within a normal range.''
• C. ''Frequent urination and burning when I urinate are expected.''
• D. ''Feelings of pelvic fullness or pelvic pressure are a sign of a problem.''

Correct answer: C

Rationale: The correct answer is 'Frequent urination and burning when I urinate are expected.' This statement by the mother indicates a need for further information because these symptoms are not normal and could indicate a urinary tract infection or another issue that needs medical attention. The other choices correctly reflect signs and symptoms that should be reported to the health care provider. Redness, swelling, or tenderness in the legs can indicate a blood clot, and feelings of pelvic fullness or pressure can be signs of a problem. Monitoring temperature is also important to ensure there is no infection or other complications postpartum.

3. A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the client's blood. On the basis of this finding, the nurse makes which determination?

• A. Hepatitis immune globulin and vaccine will be administered to the newborn infant soon after birth
• B. The results are negative.
• C. The results indicate that the mother does not have hepatitis B
• D. The client needs to receive the hepatitis B series of vaccines.

Correct answer: A

Rationale: A hepatitis B screen is performed to identify antigens in maternal blood. If antigens are present, it indicates that the mother is a carrier, and the newborn will need to receive hepatitis immune globulin and vaccine soon after birth to prevent transmission. Therefore, choice A is correct. Choices B and C are incorrect because the presence of antigens indicates a positive result, not a negative one or the absence of hepatitis B in the mother. Choice D is incorrect as it suggests the client needs to receive the hepatitis B series of vaccines, which is not the immediate action required when antigens are found in the maternal blood.

4. A nurse preparing to examine a client’s eyes plans to perform a confrontation test. The nurse tells the client that this test measures which aspect of vision?

• A. Near vision
• B. Color vision
• C. Distant vision
• D. Peripheral vision

Correct answer: D

Rationale: The correct answer is D: Peripheral vision. The confrontation test is a gross measure of peripheral vision. It compares the client’s peripheral vision with the nurse’s, assuming that the nurse’s vision is normal. During the test, the nurse positions themselves at eye level with the client, about 2 feet away, and directs the client to cover one eye with an opaque card. The nurse covers the eye opposite the client’s covered one and slowly moves a target (like a pencil) from the periphery in several directions. The client is asked to indicate when they see the target, which should coincide with when the nurse sees it. Near vision is tested using a handheld vision screener with various sizes of print, color vision with the Ishihara test, and distant vision with a Snellen chart. Therefore, choices A, B, and C are incorrect as they do not measure peripheral vision, which is the focus of the confrontation test.

5. A 37-year-old female client asks the nurse about contraception options and expresses interest in oral contraception pills. Which of the following statements would indicate that oral contraception is appropriate for this client?

• A. "I quit smoking last year, but I started again recently. Maybe I'll try to quit later this year."?
• B. "I am very diligent in taking my thyroid medications at the same time every day."?
• C. "I was hospitalized for deep vein thrombosis five years ago."?
• D. "I was recently diagnosed with breast cancer."?

Correct answer: C

Rationale: The correct answer is the statement mentioning a history of deep vein thrombosis five years ago. Oral contraceptives are generally not recommended for individuals with a history of deep vein thrombosis due to the increased risk of blood clots. Choice B, about being diligent in taking thyroid medications, does not directly relate to the safety of using oral contraceptives. Choice D, about a recent breast cancer diagnosis, would contraindicate the use of hormonal contraceptives. Choice A, mentioning a recent return to smoking, raises concerns about using hormonal contraceptives due to the increased risk of cardiovascular complications.

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