Nursing Elites

1. In which patients would the manifestation of a headache be a sign of a serious underlying disorder?

• A. A 55-year-old man with new onset of headaches that are worse at night and reported mood swings according to his family
• B. A 30-year-old woman with a unilateral throbbing headache with photophobia and nausea
• C. A 60-year-old man with his head feeling full and throbbing and muscle aching around his neck and shoulders
• D. A 40-year-old woman who experiences food cravings, gets irritable, and then develops a pulsatile-like headache on the right side of her head

Correct answer: A

Rationale: In this scenario, the correct answer is the 55-year-old man with new onset headaches that worsen at night and reported mood swings according to his family. These symptoms, especially when combined with nighttime worsening and mood changes, could indicate a serious underlying disorder such as a brain tumor or increased intracranial pressure. Choice B is incorrect as the unilateral throbbing headache with photophobia and nausea is suggestive of migraine headaches, which are usually not associated with serious underlying disorders. Choice C describes symptoms that are more indicative of tension-type headaches rather than a serious underlying disorder. Choice D presents symptoms that are more likely related to hormonal changes and migraines rather than a serious underlying disorder.

2. Which goal is a priority for a client with a DSM-IV-TR diagnosis of delirium and the nursing diagnosis Acute confusion related to recent surgery secondary to traumatic hip fracture?

• A. The client will complete activities of daily living.
• B. The client will maintain safety.
• C. The client will remain oriented.
• D. The client will understand communication.

Correct answer: B

Rationale: The correct answer is B: 'The client will maintain safety.' For a client with delirium, especially in the context of acute confusion post-surgery, safety is the top priority. Delirium can lead to disorientation, impaired decision-making, and increased risk of falls or accidents. Ensuring the client's safety by implementing measures to prevent harm is crucial. Choices A, C, and D are important but not the priority in this scenario. Completing activities of daily living, remaining oriented, and understanding communication are relevant goals but come after ensuring the client's safety in the presence of delirium and acute confusion.

3. A person is given an attenuated antigen as a vaccine. When the person asks what was given in the vaccine, how should the nurse respond? The antigen is:

• A. Alive, but less infectious
• B. Mutated, but highly infectious
• C. Normal, but not infectious
• D. Inactive, but infectious

Correct answer: A

Rationale: An attenuated antigen used in a vaccine is alive but less infectious, aiming to stimulate an immune response. Choice B is incorrect because an attenuated antigen is not highly infectious. Choice C is incorrect as the antigen is intentionally altered to be less infectious. Choice D is incorrect as an attenuated antigen is not infectious.

4. What physiological reaction occurs in the body with the 'Fight or flight' response?

• A. Increased heart rate
• B. Constricted pupils
• C. Decreased blood pressure
• D. Decreased heart rate

Correct answer: A

Rationale: The 'fight or flight' response is a primal physiological reaction that prepares the body to respond to a perceived threat or danger. This response triggers an increase in heart rate to pump more blood to the muscles and vital organs, preparing the body for action. Choice B, 'Constricted pupils,' is part of the 'fight or flight' response as well, as it helps improve focus and vision. Choice C, 'Decreased blood pressure,' is incorrect because blood pressure typically increases to ensure adequate circulation during the 'fight or flight' response. Choice D, 'Decreased heart rate,' is incorrect as the heart rate increases to supply more oxygen and nutrients to the body during times of stress.

5. A client with heart failure is experiencing pulmonary edema. Which intervention should be prioritized?

• A. Administer diuretics to reduce fluid overload.
• B. Position the client in high-Fowler's position.
• C. Administer oxygen therapy to improve oxygenation.
• D. Restrict fluid intake to prevent further fluid overload.

Correct answer: C

Rationale: In a client experiencing pulmonary edema due to heart failure, the priority intervention is to administer oxygen therapy to improve oxygenation. This helps in increasing the oxygen levels in the blood, thereby improving tissue perfusion and reducing the workload on the heart. Positioning the client in high-Fowler's position can also aid in improving oxygenation, but administering oxygen therapy directly addresses the immediate need for increased oxygen levels. Administering diuretics to reduce fluid overload and restricting fluid intake are important interventions in heart failure management, but in the acute situation of pulmonary edema, oxygen therapy takes precedence to ensure adequate oxygen supply to vital organs.

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