Nursing Elites

1. Which nursing diagnosis has the highest priority for a client with insomnia?

• A. Ineffective breathing pattern
• B. Disturbed sensory perception
• C. Ineffective coping
• D. Sleep deprivation

Correct answer: A

Rationale: The correct answer is 'A: Ineffective breathing pattern.' When a client presents with insomnia, assessing for underlying causes is crucial. Sleep apnea, an airway issue, may be a contributing factor to the client's insomnia, making 'Ineffective breathing pattern' the priority. 'Disturbed sensory perception' focuses on alterations in touch, taste, or vision, which are not directly related to insomnia. 'Ineffective coping' addresses a client's inability to manage stress, which, although important, is not the priority in this case. 'Sleep deprivation' is a consequence of insomnia rather than a primary nursing diagnosis.

2. Which of the following terms refers to soft tissue injury caused by blunt force?

• A. contusion
• B. strain
• C. sprain
• D. dislocation

Correct answer: A

Rationale: A contusion is a soft tissue injury caused by blunt force. It is an injury that does not break the skin, caused by a blow, and characterized by swelling, discoloration, and pain. The immediate application of cold might limit the development of a contusion. A strain is a muscle pull from overuse, overstretching, or excessive stress. A sprain is caused by a wrenching or twisting motion. A dislocation is a condition where the articular surfaces of the bones forming a joint are no longer in anatomical contact. Therefore, the correct answer is 'contusion' as it specifically relates to soft tissue injury caused by blunt force.

3. After administering enoxaparin (Lovenox) subcutaneously into the abdomen, which action should the nurse take?

• A. Gently rub the injection site after removing the needle
• B. Have the client maintain a side-lying position for at least five minutes
• C. Remove the needle and engage the needle safety device
• D. Apply heat to the injection site

Correct answer: C

Rationale: After administering a subcutaneous injection of enoxaparin (Lovenox) into the abdomen, the nurse should remove the needle and engage the needle safety device. Rubbing the injection site after the needle is withdrawn is not recommended as it may cause irritation and bruising. Having the client maintain a side-lying position for at least five minutes is unnecessary for a subcutaneous injection into the abdomen. Applying heat to the injection site is not indicated after administering enoxaparin subcutaneously; it could increase the risk of bleeding or bruising at the injection site.

4. What is one characteristic of human immunodeficiency virus (HIV)?

• A. The presence of circulating antibodies that neutralize HIV is evidence of exposure to HIV.
• B. HIV replication occurs intracellularly.
• C. HIV integrates its genetic material into the host cell's DNA.
• D. DNA replication is irrelevant to HIV.

Correct answer: C

Rationale: The correct answer is C. HIV integrates its genetic material into the host cell's DNA. The virus uses the enzyme reverse transcriptase to make a DNA copy of its RNA, which is then inserted into the genetic material of the infected cell. Choice A is incorrect because the presence of antibodies does not indicate immunity to HIV but rather exposure to the virus. Choice B is incorrect as HIV replication occurs intracellularly, inside the host cell. Choice D is irrelevant to the characteristics of HIV.

5. A violation of a patient's confidentiality occurs if two nurses are discussing client information in which of the following scenarios?

• A. With a physical therapist treating the patient
• B. With a social worker planning for discharge
• C. With another nurse on duty to plan for break time
• D. In the hallway outside the patient's room

Correct answer: D

Rationale: The correct answer is 'In the hallway outside the patient's room.' Discussing client information in a public area like a hallway can potentially breach patient confidentiality as it increases the risk of unauthorized individuals overhearing sensitive information. Choices A, B, and C involve discussing client information with other healthcare professionals in appropriate settings, which are more likely to maintain patient confidentiality compared to discussing in a public space like a hallway. Option D is the correct choice because it highlights a scenario where patient information is at higher risk of exposure to unauthorized individuals, hence violating patient confidentiality.

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