Nursing Elites

1. Which of these statements is true regarding advance directives?

• A. They must be reviewed and re-signed every 10 years in order to remain valid.
• B. An advance directive is legally valid in every state, regardless of the state it was created in.
• C. A physician must determine when a client is unable to make medical decisions for themselves.
• D. They cannot be honored by EMTs (emergency medical technicians) unless signed by a doctor.

Correct answer: D

Rationale: The correct statement is that advance directives cannot be honored by EMTs unless they are signed by a doctor. EMTs are required to provide emergency care to a client, irrespective of their advance directive status, unless the directive has been signed by a doctor. When a client is brought to the hospital, physicians will assess the client and implement the advance directive if necessary. Advance directives do not need to be reviewed and re-signed every 10 years to remain valid; they remain in effect until changed. While advance directives are legally valid in most states, some states may not honor those created in other states, so it's advisable to check the new state's policies if a client moves. Additionally, it typically requires two physicians, not just one, to determine if a client is unable to make medical decisions for themselves.

2. Which of the following is not an indication for pelvic ultrasonography?

• A. to measure uterine size
• B. to detect multiple pregnancies
• C. to measure renal size
• D. to detect foreign bodies

Correct answer: C

Rationale: Pelvic ultrasonography is commonly used to assess various conditions. Choices A, B, and D are all valid reasons for performing pelvic ultrasonography. Measuring uterine size helps evaluate conditions like fibroids, while detecting multiple pregnancies is essential for prenatal care. Furthermore, identifying foreign bodies can aid in diagnosing certain conditions. However, assessing renal size is typically not a primary reason for pelvic ultrasonography, making choice C the correct answer.

3. An LPN is working on the care plan for a client with diabetes mellitus. Which of these outcomes would be the most appropriate?

• A. The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.
• B. The client will maintain a blood glucose level within normal range limits today.
• C. The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.
• D. The client will maintain a blood glucose level within normal limits throughout my shift.

Correct answer: C

Rationale: The correct answer is 'The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.' This outcome is specific, measurable, and aligns with the goal of managing diabetes mellitus. Choice A is correct because it provides a clear target range (70-110) and includes adherence to facility policy, making it precise and goal-oriented. Choice B lacks specificity on the timeframe, and Choice D is vague in defining the target blood glucose range. In nursing care plans, outcomes should be well-defined, achievable, and measurable to effectively monitor the client's progress in managing their condition.

4. What is the purpose of the hydraulic lift (Hoyer lift)?

• A. To assist clients who have had orthopedic surgery.
• B. To assist clients who are unable to stand and extremely obese clients.
• C. To assist clients of all ages in a hospital setting.
• D. To assist clients with special needs.

Correct answer: B

Rationale: The purpose of the hydraulic lift, also known as the Hoyer lift, is to facilitate safe transfers for clients who cannot stand or are extremely obese. It is specifically designed for assisting clients who are unable to stand and for those who are too heavy for healthcare workers to lift safely. Choice A is incorrect because the primary purpose of a hydraulic lift is not related to orthopedic surgery. Choice C is incorrect because it is too broad and does not capture the specific use of the hydraulic lift. Choice D is incorrect because the lift is not solely for clients with special needs but rather for those who cannot stand or are extremely obese.

5. When a client with a major burn experiences body image disturbance, which of the following is an appropriate nursing intervention classification?

• A. grief work facilitation
• B. vital signs monitoring
• C. medication administration: skin
• D. anxiety reduction

Correct answer: A

Rationale: The correct answer is 'grief work facilitation' because it is a nursing intervention classification specifically designed to address disturbed body image in burn clients. The expected outcome of this intervention is grief resolution, which can help the client cope with the body image changes resulting from the burn. Choice B, 'vital signs monitoring,' is not the appropriate intervention for body image disturbance in burn clients. Vital signs monitoring is typically used for assessing physiological parameters like blood pressure, pulse rate, and temperature. Choice C, 'medication administration: skin,' is more focused on treating skin-related issues rather than addressing body image disturbance. It involves the administration of medications to promote skin healing and integrity. Choice D, 'anxiety reduction,' is aimed at managing anxiety in clients with major burns and is not specifically targeted at addressing body image disturbance. While anxiety may be a common emotional response to burns, the most appropriate intervention for body image disturbance in this scenario is 'grief work facilitation.'

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