Nursing Elites

1. When selecting patient problems for the 4-year-old child with nephrosis, what should be a priority for the nurse?

• A. Impaired body image
• B. Skin impairment
• C. Nutritional deficit
• D. Injury

Correct answer: B

Rationale: The correct answer is B: Skin impairment. Nephrosis is characterized by gross edema, making skin care a priority. Skin impairment can result from the edema and needs close monitoring and management. While nutritional deficit and injury are important considerations in patient care, they are not the priority when dealing with a child with nephrosis. Impaired body image is not typically a priority in the immediate care of a young child with nephrosis.

2. How are type IV hypersensitivity reactions different from all other types (I, II, or III) of hypersensitivity reactions?

• A. They involve antigen-antibody complexes.
• B. They are mediated by T cells and do not involve antibodies.
• C. They result in immediate allergic reactions.
• D. They are the least severe form of hypersensitivity.

Correct answer: B

Rationale: Type IV hypersensitivity reactions are mediated by T cells and cytokine release, leading to delayed reactions, unlike types I, II, and III, which involve antibodies. Choice A is incorrect because type IV reactions do not involve antigen-antibody complexes. Choice C is incorrect as type IV reactions do not result in immediate allergic reactions. Choice D is incorrect as type IV reactions are not the least severe form of hypersensitivity; in fact, they are known to cause significant tissue damage and inflammation.

3. Fluids are restricted to 1500 ml/day for a male client with AKI. He is frustrated and complaining of constant thirst, and the nurse discovers that the family is providing the client with additional fluids. What intervention should the nurse implement?

• A. Remove all sources of liquids from the client's room
• B. Allow family to give the client a measured amount of ice chips
• C. Restrict family visiting until the client's condition is stable
• D. Provide the client with oral swabs to moisten his mouth

Correct answer: D

Rationale: In this scenario, the nurse should provide the client with oral swabs to moisten his mouth. This intervention helps alleviate the client's thirst without increasing fluid intake, which is essential in managing AKI. Removing all sources of liquids from the client's room (Choice A) may not address the underlying issue of thirst and could lead to increased frustration. Allowing the family to give the client ice chips (Choice B) would add to the client's fluid intake, contradicting the restriction. Restricting family visiting (Choice C) is not necessary and does not directly address the client's thirst.

4. Which instruction should the nurse provide a client who was recently diagnosed with Raynaud's disease?

• A. Avoid cold temperatures completely.
• B. Take medications only during flare-ups.
• C. Wear gloves when removing packages from the freezer.
• D. Limit physical activity to avoid stress.

Correct answer: C

Rationale: The correct instruction for a client with Raynaud's disease is to wear gloves when handling cold items to prevent vasospasm. Raynaud's disease is characterized by vasospasm in response to cold or stress, leading to reduced blood flow to extremities. Wearing gloves when removing packages from the freezer helps minimize exposure to cold temperatures and can prevent triggering vasospasms. Choices A, B, and D are incorrect. Avoiding cold temperatures completely is impractical and may not always be possible. Taking medications only during flare-ups does not address prevention strategies, and limiting physical activity to avoid stress is not a primary intervention for Raynaud's disease.

5. Which instruction should be included in the discharge teaching plan for a client who has had a cataract extraction today?

• A. Use a metal eye shield on the operative eye during the day.
• B. Administer eye ointment after applying eye drops.
• C. Light housekeeping is safe to do, but avoid heavy lifting.
• D. Refrain from sexual activities until follow-up appointment.

Correct answer: C

Rationale: The correct instruction to include in the discharge teaching plan for a client who has had a cataract extraction is that light housekeeping is safe to do, but heavy lifting should be avoided to prevent increased intraocular pressure. Choice A is incorrect as the eye shield is usually worn at night to protect the eye. Choice B is incorrect as eye ointment is usually applied after eye drops to avoid washing away the ointment. Choice D is incorrect as sexual activities should be avoided until the follow-up appointment to prevent complications.

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