Nursing Elites

1. When assessing a 75-year-old patient who has asthma, the nurse notes that the patient assumes a tripod position, leaning forward with arms braced on the chair. How would the nurse interpret these findings?

• A. Interpret that the patient is eager and interested in participating in the interview.
• B. Evaluate the patient for abdominal pain, which may be exacerbated in the sitting position.
• C. Interpret that the patient is having difficulty breathing and assist them to a supine position.
• D. Recognize that a tripod position is often used when a patient is having respiratory difficulties.

Correct answer: D

Rationale: Assuming a tripod position"?leaning forward with arms braced on chair arms"?occurs with chronic pulmonary diseases like asthma. This position helps improve breathing by allowing better use of respiratory muscles. Option A is incorrect because assuming the tripod position is not related to being eager or interested in participating in an interview. Option B is incorrect as abdominal pain is not typically associated with the tripod position in this context. Option C is incorrect as assisting the patient to a supine position would not address the underlying respiratory difficulty indicated by the tripod position. Therefore, the correct interpretation is to recognize that the patient is likely experiencing respiratory difficulties when assuming the tripod position.

2. Which of the following is an organizational factor that affects workplace violence directed at nurses?

• A. Clients who have short hospital stays
• B. The presence of security guards
• C. Restricted client areas
• D. Understaffing of nursing personnel

Correct answer: D

Rationale: Understaffing of nursing personnel is a critical organizational factor that can contribute to workplace violence directed at nurses. When there are too few nurses on duty due to understaffing, it can lead to delays in care delivery and inadequate attention to clients' needs. This situation can result in heightened frustration, aggression, or violence from clients or their families towards the nursing staff. On the other hand, the presence of security guards (Choice B) may enhance safety in the workplace and deter violence, making it an incorrect choice. Clients who have short hospital stays (Choice A) and restricted client areas (Choice C) are not directly linked to organizational factors that promote workplace violence against nurses, making them incorrect choices.

3. When evaluating the temperature of older adults, what aspect should the healthcare provider remember about an older adult's body temperature?

• A. The body temperature of the older adult is lower than that of a younger adult.
• B. An older adult's body temperature is approximately the same as that of a young child.
• C. Body temperature varies based on the type of thermometer used.
• D. In older adults, body temperature can fluctuate widely due to less effective heat control mechanisms.

Correct answer: A

Rationale: When evaluating the temperature of older adults, it is important to note that their body temperature is usually lower than that of younger adults, with a mean temperature of 36.2�C. Choice B is incorrect because an older adult's body temperature is not approximately the same as that of a young child. Choice C is incorrect because body temperature is a physiological parameter and does not vary based on the type of thermometer used. Choice D is incorrect because while older adults may have less effective heat control mechanisms, their body temperature is typically lower, not widely fluctuating.

4. Which is the most effective action for controlling the spread of infection?

• A. Thorough hand hygiene
• B. Wearing gloves and masks when providing direct client care
• C. Implementing appropriate isolation precautions
• D. Administering broad-spectrum prophylactic antibiotics

Correct answer: A

Rationale: Thorough hand hygiene is the most effective action for controlling the spread of infection as hands are a common source of transmission. Regular and routine hand hygiene helps prevent the movement of potentially infective materials. Wearing gloves and masks is important when providing direct client care to protect both the caregiver and the patient, but it is not as effective as thorough hand hygiene in preventing overall infection spread. Implementing appropriate isolation precautions is necessary for clients with known communicable diseases, but it is not as universally effective in preventing the spread of various infections. Administering broad-spectrum prophylactic antibiotics is not an appropriate measure for controlling the spread of infection as routine use can lead to superinfection and the development of resistant organisms.

5. Your elderly patient has a temperature of 98.5 degrees. Is there anything else that a nurse should do, in addition to documenting this temperature?

• A. No, this temperature is within normal limits.
• B. No, this temperature is normally hyperthermic.
• C. Yes, this temperature is highly hyperthermic.
• D. Yes, this temperature is highly hypothermic.

Correct answer: A

Rationale: No, there is nothing else that a nurse should do. A temperature of 98.5 degrees for an elderly patient falls within normal limits. Other choices are incorrect because the temperature is not hyperthermic (abnormally high) or hypothermic (abnormally low), making choices B, C, and D inaccurate responses in this scenario.

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