Nursing Elites

1. The client is learning about lifestyle changes to manage hypertension. Which statement by the client requires further teaching?

• A. I will reduce my salt intake.
• B. I will exercise for 30 minutes most days of the week.
• C. I will drink alcohol only on the weekends.
• D. I will monitor my blood pressure regularly.

Correct answer: C

Rationale: The correct answer is C. Clients with hypertension should ideally avoid or limit alcohol intake rather than just restricting it to weekends. Excessive alcohol consumption can raise blood pressure and interfere with the effectiveness of hypertension management. Choices A, B, and D are all positive statements that align with managing hypertension: reducing salt intake, regular exercise, and monitoring blood pressure are all beneficial lifestyle changes for individuals with hypertension. Therefore, the statement about drinking alcohol only on weekends requires further teaching to emphasize the importance of reducing alcohol consumption for better blood pressure control.

2. During a skin assessment, a healthcare professional is observing a group of clients. Which of the following lesions should the healthcare professional identify as vesicles?

• A. Acne
• B. Warts
• C. Psoriasis
• D. Herpes simplex

Correct answer: D

Rationale: Vesicles are small fluid-filled blisters. Herpes simplex is an example of a vesicular lesion, characterized by small, fluid-filled blisters. Acne presents as comedones, papules, pustules, or nodules, not vesicles. Warts are caused by the human papillomavirus and appear as rough, raised growths. Psoriasis is a chronic autoimmune condition that results in red, scaly patches on the skin, not vesicles.

3. A client with a history of severe anxiety is scheduled for surgery. Which preoperative medication is the most appropriate for the LPN/LVN to administer to this client?

• A. Lorazepam (Ativan)
• B. Morphine sulfate
• C. Meperidine (Demerol)
• D. Promethazine (Phenergan)

Correct answer: A

Rationale: Lorazepam (Ativan) is the most appropriate preoperative medication for a client with severe anxiety. Lorazepam belongs to the benzodiazepine class and is commonly used to manage anxiety before surgical procedures due to its anxiolytic properties. Morphine sulfate and Meperidine (Demerol) are opioid analgesics, not typically indicated for preoperative anxiety. Promethazine (Phenergan) is an antihistamine used for nausea and vomiting, not anxiety management.

4. A client is experiencing dyspnea and fatigue after completing morning care. Which of the following actions should the nurse include in the client’s plan of care?

• A. Schedule rest periods during morning care.
• B. Discontinue morning care for 2 days.
• C. Perform all care as quickly as possible.
• D. Ask a family member to come in to bathe the client.

Correct answer: A

Rationale: Scheduling rest periods during morning care is essential for managing dyspnea and fatigue in the client. This approach allows the client to pace themselves and catch their breath, promoting comfort and reducing symptoms. It is crucial to provide breaks to prevent overwhelming the client and exacerbating their symptoms. Discontinuing morning care for 2 days (choice B) is not a suitable solution as it does not address the underlying issue and may lead to neglect of essential care. Performing all care as quickly as possible (choice C) can worsen the client's symptoms and compromise their well-being by increasing stress and exertion. Asking a family member to bathe the client (choice D) does not address the need for rest periods during care and may not be feasible or appropriate in all situations.

5. The patient refuses to bathe in the morning, stating a preference for evening baths. What is the best action for the nurse?

• A. Defer the bath until evening and pass on the information to the next shift.
• B. Tell the patient that daily morning baths are part of the 'normal' routine.
• C. Explain the importance of maintaining morning hygiene practices.
• D. Cancel hygiene for the day and attempt again in the morning.

Correct answer: A

Rationale: The best action by the nurse is to respect the patient's preference and autonomy. Defer the bath until evening to allow the patient to follow their usual hygiene routine. Passing on the information to the next shift ensures continuity of care. Choice B is incorrect because it disregards the patient's preference and autonomy. Choice C, while important, does not address the patient's immediate concern. Choice D is incorrect as it does not respect the patient's wishes and may lead to further resistance to bathing.

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