Nursing Elites

1. Which of the following interventions should be considered the highest priority when caring for June, who has hemiparesis secondary to a stroke?

• A. Position June in an upright lateral position
• B. Perform range of motion exercises
• C. Apply antiembolic stockings
• D. Use hand rolls or pillows for support

Correct answer: C

Rationale: The correct answer is C, 'Apply antiembolic stockings'. In the case of a patient who has experienced a stroke and is suffering from hemiparesis, the highest priority intervention is to prevent further complications such as deep vein thrombosis (DVT), which can be life-threatening. Antiembolic stockings are used to increase venous blood flow velocity and reduce the risk of DVT. Choice 'A', positioning June in an upright lateral position, while important for overall care, is not the highest priority. Choice 'B', performing range of motion exercises, is an important part of recovery but not the immediate priority. Choice 'D', using hand rolls or pillows for support, is also a valuable intervention but does not address the most pressing risk of further complications.

2. Low levels of physical activity are more commonly associated with which type of cancer?

• A. Esophageal cancer
• B. Pancreatic cancer
• C. Lung cancer
• D. Colon cancer

Correct answer: D

Rationale: Low physical activity is most strongly associated with an increased risk of colon cancer. Regular exercise helps regulate bowel movements and reduce inflammation, which are factors that can contribute to the development of colon cancer. Esophageal cancer, pancreatic cancer, and lung cancer are not as directly linked to low levels of physical activity.

3. Hypertrophic burn scars are caused by:

• A. exaggerated contraction
• B. random layering of collagen
• C. wound ischemia
• D. delayed epithelialization

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

4. In a patient with liver cirrhosis, weight gain due to fluid retention can mask the symptoms of what condition?

• A. Liver failure
• B. Gallbladder disease
• C. Heart failure
• D. Protein-Energy Malnutrition (PEM)

Correct answer: D

Rationale: In a patient with liver cirrhosis, weight gain due to fluid retention can mask Protein-Energy Malnutrition (PEM) symptoms. This can lead to an increase in weight, making it challenging to identify weight loss or muscle wasting associated with PEM. Therefore, option D is correct. Options A, B, and C are incorrect because fluid retention and weight gain related to liver cirrhosis do not necessarily hide the symptoms of liver failure, gallbladder disease, or heart failure.

5. An appropriate nursing diagnosis for clients in the acute manic phase of bipolar disorder is:

• A. Risk for injury directed to self
• B. Risk for injury directed to others
• C. Impaired nutrition less than body requirements
• D. Ineffective individual coping

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

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