Nursing Elites

1. The PN is assisting the recreational director of a long-term care facility to plan outdoor activities for wheelchair-bound older residents who are mentally alert. Which activity meets the physical and social needs of these residents?

• A. An open-air concert
• B. A tea party in the courtyard
• C. A team ring-toss competition
• D. A picnic in the park

Correct answer: B

Rationale: A tea party in the courtyard is the most suitable activity as it allows for social interaction in a comfortable and accessible environment. Wheelchair-bound residents can easily participate, fostering both physical and social engagement. An open-air concert may pose challenges regarding accessibility and comfort for wheelchair-bound individuals. A team ring-toss competition involves physical activity that may not be inclusive for all residents, especially those in wheelchairs. A picnic in the park may also present challenges related to accessibility and comfort for wheelchair-bound individuals.

2. While assessing an older male client who takes psychotropic medications, the nurse observes uncontrollable hand movements and excessive blinking. Which information in the client's medical record should the nurse review?

• A. Prescription for lorazepam
• B. History of Parkinson's disease
• C. Screening for tardive dyskinesia
• D. Recent urine drug screen report

Correct answer: C

Rationale: The symptoms of uncontrollable hand movements and excessive blinking are indicative of tardive dyskinesia, a possible side effect of long-term use of psychotropic medications. Reviewing the screening for tardive dyskinesia is crucial to assess if these symptoms are related to the medication. Option A, the prescription for lorazepam, is less relevant as the focus should be on potential side effects rather than the specific medication. Option B, history of Parkinson's disease, is not directly related to the observed symptoms, which are more likely linked to medication side effects. Option D, recent urine drug screen report, is not as pertinent in this context compared to reviewing the screening for tardive dyskinesia.

3. A nurse is assisting in the admission of a young adult female Korean exchange student with acute abdominal pain. When asked about her sexual activity, she looks away. What should the nurse do?

• A. Omit this question from the assessment form
• B. Ask her if she would like an interpreter present to assist with communication
• C. Reword the question to ensure the client's understanding
• D. Watch the client's response when asked a different question

Correct answer: D

Rationale: Observing the client's response to a different question can help gauge her comfort level and understanding, which is essential in culturally sensitive care. By watching her response to a different question, the nurse can assess if the discomfort is related to the specific question or a broader issue. Omitting the question may result in missing crucial information. Asking about an interpreter assumes that the language barrier is the only issue, which may not be the case. Rewording the question may not address the underlying discomfort and could still lead to misinterpretation.

4. When caring for a client with colostomy, which topical skin preparation should the PN apply around the stoma?

• A. Antiseptic cream
• B. Petroleum jelly
• C. Cornstarch
• D. Stomadhesive

Correct answer: D

Rationale: The correct answer is 'Stomadhesive.' Stomadhesive is a protective barrier used around the stoma to prevent skin irritation and to secure the colostomy bag. This preparation helps to maintain skin integrity and prevent complications such as skin breakdown. Antiseptic cream (Choice A) is not typically used around the stoma as it can irritate the skin. Petroleum jelly (Choice B) is also not recommended as it can interfere with the adhesive properties of the colostomy appliance. Cornstarch (Choice C) is not suitable for application around the stoma as it can promote moisture and lead to skin irritation.

5. At 1200, the practical nurse learns that a client's 0900 dose of an anticonvulsant was not given. The next scheduled dose is at 2100. Which action should the PN take?

• A. Administer half of the missed dose immediately
• B. Administer the missed dose as soon as possible
• C. Give the missed dose with the next scheduled dose
• D. Withhold the missed dose unless seizure activity occurs

Correct answer: B

Rationale: Administering the missed dose as soon as possible is crucial in this situation. Missing an anticonvulsant dose can lead to breakthrough seizures, which are harmful to the client. Administering the missed dose promptly helps maintain the therapeutic level of the medication and reduces the risk of seizure activity. Giving half the dose may not provide adequate protection against seizures. Delaying the dose until the next scheduled time increases the time the client is without the medication, potentially increasing the risk of seizures. Withholding the missed dose unless seizure activity occurs is not recommended, as prevention is key in managing anticonvulsant therapy.

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