Nursing Elites

1. Which of the following would be the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery?

• A. Client will increase mobility by the time of discharge from hospital
• B. Client will demonstrate effective breathing pattern when ambulating throughout hospital stay
• C. Client will increase activity tolerance by discharge from the hospital
• D. Client will remain free from falls throughout their hospital stay

Correct answer: D

Rationale:

2. What is the condition called when the client's pupils are different sizes and have been this way since childhood?

• A. Exophthalmos
• B. Anisocoria
• C. Strabismus
• D. Scleral edema

Correct answer: B

Rationale: Anisocoria is the correct answer. Anisocoria is the condition of having pupils of different sizes. Exophthalmos refers to abnormal protrusion of the eyeball, not pupil size difference. Strabismus is a condition where the eyes are not properly aligned with each other. Scleral edema is swelling of the sclera, the white part of the eye, and not related to differing pupil sizes.

3. A wound has a blood-tinged liquid that is dripping from the surgical site. How does the nurse document this finding?

• A. Creamy pus
• B. Serous
• C. Serosanguineous
• D. Purulent exudate

Correct answer: C

Rationale:

4. What is a classic symptom assessed in clients with lupus?

• A. Butterfly rash
• B. Chvostek's sign
• C. Ovid's sign
• D. Heberden's nodes

Correct answer: A

Rationale:

5. A client with systemic lupus erythematous complains of flank pain. Which laboratory test does the nurse anticipate will be ordered?

• A. Platelets
• B. Skin biopsy
• C. Creatinine
• D. Hemoglobin

Correct answer: C

Rationale:

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