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. When a person using over-the-counter nasal decongestant drops experiences unrelieved and worsening nasal congestion, what should be instructed?

• A. switch to a stronger dose of the same medication.
• B. discontinue the medication for a few weeks.
• C. continue taking the same medication, but use it more frequently.
• D. use a combination of medications for better relief.

Correct answer: B

Rationale: When a person using over-the-counter nasal decongestant drops experiences unrelieved and worsening nasal congestion, it is crucial to discontinue the medication for a few weeks. Prolonged use of decongestant drops can lead to rebound congestion, which is relieved by stopping the medication for a period of time. Nasal congestion occurs due to various factors like infection, inflammation, or allergy, leading to swelling of the nasal cavity. Nasal decongestants work by stimulating alpha-adrenergic receptors, causing vasoconstriction and shrinking of nasal mucous membranes. However, prolonged use can result in vasodilation, worsening nasal congestion. Switching to a stronger dose of the same medication is not recommended as it can exacerbate the issue. Continuing the same medication more frequently or using a combination of medications are also not advised and may lead to side effects. Educating individuals on proper decongestant use and potential risks of prolonged usage is essential, especially for those with specific health conditions.

3. At what age will vision be 20/20 in children?

• A. 4 years old
• B. 5 years old
• C. 6 years old
• D. 7 years old

Correct answer: C

Rationale: The correct answer is 6 years old. At this age, children typically have the potential for 20/20 vision. This is considered the standard age for achieving optimal vision clarity. Choices A, B, and D are incorrect as they are not typically associated with the age at which children achieve 20/20 vision.

4. A healthcare professional is reviewing a patient's arterial blood gas values. Which of the following conditions apply under the following values? pH- 7.49 Bicarbonate ion 24 mEq/dl PaCO2 - 31 mmHg PaO2 - 52 mmHg FiO2 - 0.22

• A. respiratory acidosis
• B. respiratory alkalosis
• C. metabolic acidosis
• D. metabolic alkalosis

Correct answer: B

Rationale: The given blood gas values indicate respiratory alkalosis. A high pH and low PaCO2 level are consistent with respiratory alkalosis. In this scenario, no compensation for the alkalosis is noted, ruling out metabolic acidosis or alkalosis. Metabolic conditions would usually involve changes in bicarbonate levels, which remain within the normal range in this case.

5. A client had a colostomy done one day ago. Which of the following is an abnormal finding when assessing the stoma?

• A. mild edema
• B. minimal bleeding
• C. rose color
• D. dark red color

Correct answer: D

Rationale: A dark red color is an abnormal finding when assessing the stoma as it indicates inadequate blood supply, possibly due to ischemia. Mild edema, minimal bleeding, and a rose color are expected findings one day post colostomy surgery. Mild edema can be present due to tissue trauma and inflammation, minimal bleeding can occur initially, and a healthy stoma typically appears pink to red, known as a rose color, indicating good blood supply and tissue perfusion. Therefore, the dark red color is the abnormal finding in this scenario.

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