Nursing Elites

1. What kind of preventive measures is MOST likely to be used to prevent Mary Eden from falling due to her muscular frailty?

• A. Physical therapy for muscle strengthening exercises
• B. Physical therapy for range of motion exercises
• C. Occupational therapy to help her with confusion
• D. Medications to help her sleep more

Correct answer: A

Rationale: Mary Eden, due to her muscular frailty, is at risk of falling. The most effective preventive measure in this case would be physical therapy focusing on muscle strengthening exercises. Strengthening exercises can help improve her muscle tone and stability, reducing the risk of falls. While range of motion exercises may be beneficial, they may not directly address her muscular frailty and stability concerns as effectively as muscle strengthening exercises. Occupational therapy aims to help individuals with activities of daily living and functional tasks, not confusion. Medications to induce more sleep can actually increase the risk of falls due to potential side effects like dizziness or disorientation, rather than preventing falls.

2. A nurse is assisting a pregnant client who is having an amniocentesis. Which of the following statements by the nurse indicates the correct teaching for this procedure?

• A. I'm going to help you lie lat on your back for this."
• B. Don't worry, I'm sure everything will be all right."
• C. I will need to help you remove your shirt for this procedure."
• D. Now that the procedure is inished, I will put a small bandage over the puncture site."

Correct answer: D

Rationale: An amniocentesis is performed to draw amniotic luid from the sac around the fetus during pregnancy. It may be analyzed for certain disorders or complications associated with pregnancy. Following the procedure, the nurse should wash the client's abdomen and place a small bandage over the puncture site

3. Gio told his nurse that the FBI is monitoring and recording his every movement and that microphones have been placed in the unit walls. Which action would be the most therapeutic response?

• A. Confront the delusional material directly by telling Gio that this simply is not so.
• B. Tell Gio that this must seem frightening to him but that you believe he is safe here.
• C. Tell Gio to wait and talk about these beliefs in his one-on-one counseling sessions.
• D. Isolate Gio when he begins to talk about these beliefs.

Correct answer: B

Rationale: The most therapeutic response in this situation is to acknowledge Gio's feelings of fear and validate his experience by expressing empathy ('this must seem frightening to him'). By reassuring Gio that he is safe in the current environment, the nurse can help reduce his anxiety and build trust. Choice A is not recommended as directly confronting delusional beliefs may lead to increased distress and resistance. Choice C delays addressing Gio's concerns and may not provide immediate support. Choice D of isolating Gio can worsen his feelings of paranoia and distrust in the treatment setting.

4. Mary T. was admitted to a nursing home on May 1st. On July 4th, she was diagnosed with a skin infection. This infection is considered a ________________ infection.

• A. nosocomial
• B. systemic
• C. resident flora
• D. resident aura

Correct answer: A

Rationale: The correct answer is 'nosocomial.' A nosocomial infection is defined as one that is not present upon admission to a healthcare facility but instead occurs during the patient's stay. In this case, since Mary was diagnosed with a skin infection after being admitted to the nursing home, it is considered a nosocomial infection. Nosocomial infections are a significant concern in healthcare settings, and infection control measures are in place to prevent their spread. Choices B, C, and D are incorrect. 'Systemic' refers to a condition affecting the entire body, not specific to a healthcare setting. 'Resident flora' and 'resident aura' are not commonly used terms in healthcare and do not relate to infections acquired in healthcare facilities.

5. You are caring for an infant who is just about 12 months old. Which assessment data is normal for the infant at this age?

• A. The infant had doubled their birth weight at twelve months.
• B. The infant had tripled their birth weight at twelve months.
• C. The mother reports that the infant is drinking 60 mLs per kilogram of its body weight.
• D. The infant had grown � inch since last month.

Correct answer: A

Rationale: The normal assessment data for the infant at 12 months of age is that the infant has doubled their birth weight at 12 months of age. The mother's reports that the infant is drinking 60 mLs per kilogram of its body weight and the fact that the infant had grown � inch since last month are not normal assessment data. Infants are fed breast milk or formula every two to four hours with a total daily intake of 80 to 100 mLs per kilogram of body weight. As the neonate grows, they gain five to seven ounces during the first six months and then they double their birth weight during the first year; the head circumference increases a half inch each month for six months and then two tenths of an inch until the infant is one year of age. Similarly, the height or length of the newborn increases an inch a month for the first 6 months and then 1/2 inch a month until the infant is 1 year of age.

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