Nursing Elites

1. What does the nurse perform to determine the family nursing problems/needs?

• A. goal setting
• B. family health care plan formulation
• C. assessment
• D. evaluation

Correct answer: C

Rationale: The correct answer is C: assessment. Assessment is the initial step in identifying family nursing problems/needs. During assessment, the nurse collects data to understand the family's health status, strengths, weaknesses, and potential areas for intervention. This process helps in developing an accurate picture of the family's situation. Choices A, B, and D are incorrect because goal setting, family health care plan formulation, and evaluation come after the assessment phase. Goal setting occurs once the issues are identified, the family health care plan is developed based on assessment findings, and evaluation is the final step to assess the effectiveness of the interventions implemented.

2. Following-up Mrs. Luy, G5P4, you notice her eldest son is underweight and her youngest daughter looks thin and pale. Mrs. Luy's present pregnancy would mean another additional member of the family. This can be considered as:

• A. health deficit
• B. health deficit and health threat
• C. health threat
• D. foreseeable crisis

Correct answer: C

Rationale: The correct answer is C: 'health threat.' The new pregnancy poses a health threat due to the potential strain on resources and the existing issues with the children, such as underweight and being pale. Choice A is incorrect as it does not fully capture the potential risks associated with the new pregnancy. Choice B is also incorrect as it includes 'health deficit,' which is not explicitly mentioned in the scenario. Choice D, 'foreseeable crisis,' is not the most fitting description of the situation presented.

3. During a visit to the community health clinic, a 45-year-old Native American female, who has a BMI of 35, complains of changes in her vision. Which condition is most important for the RN to be aware of in the client's family history?

• A. Diabetes
• B. Glaucoma
• C. Hypertension
• D. Brain Tumor

Correct answer: A

Rationale: The correct answer is A: Diabetes. Given the client's Native American ethnicity, high BMI, and vision changes, diabetes is the most crucial condition for the nurse to be aware of in the client's family history. Diabetes is strongly associated with vision problems, especially diabetic retinopathy. Glaucoma (choice B) is a condition that affects the optic nerve and can lead to vision loss but is not as directly linked to the client's BMI and ethnic background. Hypertension (choice C) can also impact vision, but in this case, diabetes takes precedence based on the client's profile. Brain tumor (choice D) is less likely to be related to the client's BMI, ethnicity, and vision changes compared to diabetes.

4. The home health care agency can expect to obtain Medicare reimbursement for which home visit performed by a registered nurse or a practical nurse?

• A. assessment of the speech pattern of a mobile adult who had a mild stroke last year
• B. safety teaching for an older male client whose wife complains that he uses an unsafe ladder while painting
• C. wound care for a client who had postoperative infection following abdominal surgery two weeks ago
• D. evaluation of crutch use by a 65-year-old client who broke his tibia while snow skiing

Correct answer: C

Rationale: The correct answer is C because wound care for a postoperative infection qualifies for Medicare reimbursement. Medicare typically covers skilled nursing care, like wound care, required due to a postoperative infection. Choices A, B, and D involve assessments, teaching, and evaluation, which may not always be eligible for Medicare reimbursement unless they are directly related to skilled nursing care for a specific medical condition.

5. Which one of the following statements, if made by the client, indicates teaching about Inderal (propranolol) has been effective?

• A. ''I may experience seizures if I stop the medication abruptly.''
• B. ''I may experience an increase in my heart rate for a few weeks.''
• C. ''I can expect to feel nervousness the first few weeks.''
• D. ''I can have a heart attack if I stop this medication suddenly.''

Correct answer: D

Rationale: The correct answer is D. Stopping Inderal (propranolol) abruptly can cause rebound hypertension, angina, and even a myocardial infarction (heart attack), so it is crucial to taper off the medication under medical supervision. Choices A, B, and C are incorrect because they do not reflect the serious consequences associated with abrupt discontinuation of propranolol.

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