Nursing Elites

1. Which client is at highest risk for developing a pressure ulcer?

• A. 23 year-old in traction for fractured femur
• B. 72 year-old with peripheral vascular disease, who is unable to walk without assistance
• C. 75 year-old with left sided paresthesia and is incontinent of urine and stool
• D. 30 year-old who is comatose following a ruptured aneurysm

Correct answer: C

Rationale: Risk factors for pressure ulcers include: immobility, absence of sensation, decreased LOC, poor nutrition and hydration, skin moisture, incontinence, increased age, decreased immune response. This client has the greatest number of risk factors.

2. Which of the following statements made by a client during an individual therapy session would the nurse most identify as reflecting schizoaffective disorder?

• A. ''I just want to stab myself with this pen.''
• B. ''What's the point in life anyways?''
• C. ''My thoughts are racing because of the conspiracies against me.''
• D. ''I hear voices every day and sometimes see old friends that don't exist.''

Correct answer: C

Rationale: The correct answer is, ''My thoughts are racing because of the conspiracies against me.'' Schizoaffective disorder combines the symptoms of bipolar disorder (mania and depression) with those of schizophrenia (delusions and disturbed thought processes). Racing thoughts are a characteristic symptom of a manic episode, while beliefs in conspiracies indicate paranoia, which are common in schizoaffective disorder. Choices A, B, and D do not specifically align with the symptoms of schizoaffective disorder. Choice A suggests self-harm, which may be seen in various mental health conditions; choice B reflects existential questioning or depression; and choice D describes hallucinations, which are more characteristic of schizophrenia rather than schizoaffective disorder.

3. A 49-year-old patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information will the nurse include in patient teaching?

• A. Recommendation to drink at least 4 L of fluid daily
• B. Need to avoid driving or operating heavy machinery
• C. How to draw up and administer injections of the medication
• D. Use of contraceptive methods other than oral contraceptives

Correct answer: C

Rationale: When initiating treatment with glatiramer acetate (Copaxone), patient education should focus on teaching the patient how to draw up and administer injections of the medication. Copaxone is administered via self-injection, hence understanding the correct technique is crucial for successful treatment. Recommendations regarding fluid intake or the need to avoid driving heavy machinery are not directly related to glatiramer acetate therapy. Additionally, while discussing contraceptive methods may be important, the use of oral contraceptives does not specifically contraindicate the use of glatiramer acetate.

4. A patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving nifedipine (Procardia). Which assessment would best indicate to the nurse that the patient's condition is improving?

• A. Blood pressure (BP) is less than 140/90 mm Hg.
• B. Patient reports decreased exertional dyspnea
• C. Heart rate is between 60 and 100 beats/minute
• D. Patient's chest x-ray indicates clear lung fields

Correct answer: B

Rationale: The correct answer is for the patient to report decreased exertional dyspnea. In idiopathic pulmonary arterial hypertension (IPAH), exertional dyspnea is a significant symptom indicating disease severity. Improvement in this symptom suggests that the medication, nifedipine, is effective in managing the condition. While nifedipine can affect blood pressure (choice A) and heart rate (choice C), these parameters are not specific indicators for monitoring IPAH improvement. Choice D, clear lung fields on the chest x-ray, does not directly correlate with the effectiveness of therapy for IPAH. Therefore, the most relevant assessment to monitor improvement in a patient with IPAH receiving nifedipine is a decrease in exertional dyspnea.

5. After an unimmunized individual is exposed to hepatitis B through a needle-stick injury, which actions will the nurse plan to take (select one that does not apply)?

• A. Administer hepatitis B vaccine.
• B. Test for antibodies to hepatitis B.
• C. Teach about alpha-interferon therapy.
• D. Give hepatitis B immune globulin.

Correct answer: C

Rationale: In the case of exposure to hepatitis B, the nurse should plan to administer hepatitis B vaccine to provide active immunity. Testing for antibodies to hepatitis B is essential to determine the individual's immune status. Giving hepatitis B immune globulin is necessary for passive immunity in cases of exposure. However, teaching about alpha-interferon therapy is not part of the standard management for hepatitis B exposure. Interferon therapy and oral antivirals are typically used in the treatment of chronic hepatitis B infections, not for prophylaxis after exposure.

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