Nursing Elites

1. When assessing the integumentary system of a client with anorexia nervosa, which finding would support the diagnosis?

• A. Preoccupation with calories
• B. Thick body hair
• C. Sore tongue
• D. Dry, brittle hair

Correct answer: D

Rationale: The correct answer is D: Dry, brittle hair. Dry, brittle hair is a common sign of malnutrition, often seen in clients with anorexia nervosa. Preoccupation with calories (choice A) is more related to the psychological aspect of anorexia rather than a physical finding. Thick body hair (choice B) is not typically associated with anorexia nervosa. A sore tongue (choice C) can be seen in conditions like vitamin deficiencies or oral health issues but is not specific to anorexia nervosa.

2. Identifying the strengths and weaknesses in the nursing care plan is part of which of the following steps in determining and fulfilling the patient's nursing care needs?

• A. Evaluation
• B. Planning
• C. Implementation
• D. Assessment

Correct answer: A

Rationale: Correct. Evaluation involves assessing the effectiveness of the nursing care plan by identifying its strengths and weaknesses. This step helps in determining if the plan is meeting the patient's needs. Choice B (Planning) is incorrect because planning involves developing the nursing care plan based on the assessment of the patient's needs. Choice C (Implementation) is incorrect as it refers to putting the nursing care plan into action. Choice D (Assessment) is incorrect as assessment is the initial step in the nursing process, involving data collection and analysis to identify the patient's needs.

3. The nurse has given post-procedure instructions to a client who underwent a colonoscopy. Evaluation of learning would be evident if the client makes which statement(s)?

• A. All below
• B. “My abdominal muscles may be tender because of the procedure.”
• C. “My diet should be light at first, and then I can progress to a regular diet.”
• D. “It is normal to feel gassy or bloated for a short while after the procedure.”

Correct answer: A

Rationale: Mild tenderness, a light diet initially, and gas or bloating are expected after a colonoscopy.

4. The client has been diagnosed with hemorrhoids. Which statement from the client indicates that further teaching is needed?

• A. “I should increase fruits, bran, and fluids in my diet.”
• B. “I will use warm compresses and take sitz baths daily.”
• C. “I must take a laxative every night and have a stool daily.”
• D. “I can use an analgesic ointment or suppository for pain.”

Correct answer: C

Rationale: Choice C indicates the need for further teaching because regular use of laxatives can lead to dependence and is not recommended for hemorrhoids. Increased fiber intake and fluid consumption (Choice A) help prevent constipation, warm compresses and sitz baths (Choice B) provide relief, and using analgesic ointments or suppositories (Choice D) can help manage pain associated with hemorrhoids.

5. The nurse is preparing to assist in examining a Hispanic child who was brought to the clinic by the mother. During the assessment of the child, the nurse should take which action(s)?

• A. Admiring the child
• B. Taking the child’s temperature
• C. A, D
• D. Obtaining an interpreter if necessary

Correct answer: C

Rationale: In a multicultural healthcare setting, it's essential for the nurse to build rapport with the child and family. Admiring the child can help establish trust and comfort. Additionally, since the child's mother brought them to the clinic, it's crucial to ensure effective communication. Obtaining an interpreter, if necessary, is vital for clear and accurate information exchange. Taking the child's temperature, while important in a physical assessment, is not specifically highlighted in this scenario. Therefore, choices A and B alone are not sufficient, making the correct answer C, which includes both building rapport by admiring the child and ensuring clear communication by obtaining an interpreter if needed.

Similar Questions