Nursing Elites

1. Which is an appropriate outcome for the nursing diagnosis of Body Image Disturbance for a client with anorexia nervosa?

• A. The client verbalizes knowledge of a maintenance diet.
• B. The client demonstrates assertiveness with family.
• C. The client verbalizes her body size accurately.
• D. The client demonstrates control of obsessive behaviors.

Correct answer: C

Rationale: The correct answer is 'The client verbalizes her body size accurately.' For clients with anorexia nervosa, body image disturbance is a common issue where they perceive themselves inaccurately. Verbalizing her body size accurately indicates progress towards correcting this distorted self-perception. Choices A, B, and D are incorrect because they do not directly address the distorted body image perception seen in clients with anorexia nervosa. Choice A focuses on knowledge of a maintenance diet, which is unrelated to body image perception. Choice B involves assertiveness with family, which is more related to family dynamics. Choice D addresses control of obsessive behaviors, which is not directly related to correcting the distorted body image perception.

2. The LPN is auscultating for bowel sounds and hears between 3 and 4 bowel sounds per minute. This is a somewhat expected finding for which of these clients?

• A. a 63-year-old female undergoing chemotherapy for breast cancer
• B. a 56-year-old female with dementia undergoing a swallow study
• C. a 34-year-old male with a PEG tube newly admitted for diabetic ketoacidosis
• D. a 45-year-old male recovering from a knee replacement under general anesthesia

Correct answer: D

Rationale: When recovering from general anesthesia, hypoactive bowel sounds can be expected due to the effects of the anesthesia on gut motility. For the other clients, hearing less than 5 bowel sounds per minute would indicate an abnormal finding. In the context of the given situation, the client recovering from knee replacement surgery aligns with the expected range of bowel sounds post-general anesthesia. Therefore, choice D is the correct answer. Choices A, B, and C present scenarios where hearing less than 5 bowel sounds per minute would be abnormal, indicating potential issues that need further evaluation.

3. A health care provider writes a medication prescription in a client's record. While transcribing the prescription, the nurse notes that the prescribed dose is three times higher than the recommended dose. The nurse calls the health care provider, who states that this is the dose that the client takes at home and that it is acceptable for this client's condition. What is the appropriate action for the nurse to take?

• A. Verifying the prescribed dose with the client before administering the medication
• B. Contacting the nursing supervisor
• C. Asking the nurse assigned to care for the client to administer the medication
• D. Continuing to transcribe the prescription

Correct answer: B

Rationale: In this scenario, the nurse has identified a significant discrepancy between the prescribed dose and the recommended dose. While the health care provider has justified the higher dose based on the client's home regimen, the nurse's primary responsibility is to ensure patient safety. If a nurse has concerns about a prescription being incorrect or potentially harmful, they should seek further clarification from the health care provider. Since the nurse still believes the dose is inappropriate after discussing with the health care provider, the next appropriate action is to contact the nursing supervisor. Continuing to transcribe the prescription without addressing the concern could jeopardize the client's safety. Asking another nurse to administer the medication without proper resolution of the dosage concern would also pose a risk to the client. While verifying the prescribed dose with the client is important, in this situation, the nurse should first escalate the issue to the nursing supervisor to ensure appropriate actions are taken.

4. Which of the following symptoms is not indicative of autonomic dysreflexia in the client with a spinal cord injury?

• A. sudden onset of headache
• B. flushed face
• C. hypotension
• D. nasal congestion

Correct answer: C

Rationale: Autonomic dysreflexia is characterized by a sudden onset of symptoms due to an overactive autonomic nervous system. Hypotension is not indicative of autonomic dysreflexia; instead, hypertension is a hallmark sign. Therefore, hypotension is the correct answer. Flushed face, sudden onset of headache, and nasal congestion are classic symptoms of autonomic dysreflexia caused by a noxious stimulus below the level of the spinal cord injury. These symptoms result from the body's attempt to regulate blood pressure when the normal feedback loop is interrupted.

5. The LPN is caring for a 32-year-old female client who is 8 hours post-op after a tonsillectomy. Which of these actions would be appropriate for the nurse to take?

• A. Inform the client that ear pain may occur and is normal.
• B. Provide ice water and a straw to promote easy fluid consumption.
• C. Provide hot tea to soothe the throat.
• D. Monitor vitals every 15 minutes.

Correct answer: A

Rationale: The appropriate action for the nurse to take is to inform the client that ear pain may occur and is normal after a tonsillectomy. Referred pain in the ear is common due to related nerve pathways. It is essential to educate the client about this to alleviate concerns. Providing ice water and a straw is not recommended as they may irritate the throat and disturb the healing process. Hot beverages like tea should also be avoided for the same reason. While monitoring vitals every 15 minutes is crucial in the immediate postoperative period for early identification of any complications, it is not the most appropriate action in this scenario where addressing the client's concerns and providing education is key.

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