Nursing Elites

1. What is the priority nursing diagnosis for a client with immobility?

• A. Constipation related to immobility
• B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
• C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
• D. Risk for disuse syndrome as evidenced by immobility

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.

2. A client is experiencing numbness and tingling distal to a new arm cast with no increase in pain. The nurse assesses that the client's fingers are pale, cool and swollen. What action does the nurse take next?

• A. Remove the cast to decrease pressure
• B. Raise the arm above the level of the heart
• C. Apply heat to the affected hand
• D. Encourage range of motion

Correct answer: B

Rationale:

3. What health teaching would not help an older adult avoid a musculoskeletal injury?

• A. Avoid home modification
• B. Wear a helmet when riding a bicycle
• C. Osteoporosis screening
• D. Fall prevention

Correct answer: A

Rationale: Avoiding home modifications can increase the risk of falls and injuries in older adults.

4. A client is diagnosed with glaucoma. The provider needs to determine if it is open-angle glaucoma or closed-angle glaucoma. What test does the nurse anticipate?

• A. Ultrasonic imaging
• B. Gonioscopy
• C. Corneal staining
• D. Electroretinography

Correct answer: B

Rationale: Gonioscopy is the appropriate test to anticipate in this scenario. It is used to distinguish between open-angle and closed-angle glaucoma by examining the angle where the iris meets the cornea. Choice A, ultrasonic imaging, is not typically used to differentiate between these types of glaucoma. Choice C, corneal staining, is used to detect corneal abrasions and defects, not to differentiate between types of glaucoma. Choice D, electroretinography, is a test that measures the electrical responses of various cell types in the retina and is not specific to differentiating between open-angle and closed-angle glaucoma.

5. Which of the following nonpharmacological methods cannot be used to manage the chronic pain of a client with rheumatoid arthritis?

• A. Adequate rest
• B. Heat for 20-30 minutes
• C. Hot showers
• D. Ice for 2 hours at a time

Correct answer: D

Rationale:

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