Nursing Elites

1. A client diagnosed with dementia is disoriented, wandering, has a decreased appetite, and is having trouble sleeping. What is the priority nursing problem for this client?

• A. Disturbed thought processes.
• B. Altered sleep pattern.
• C. Imbalanced nutrition: less than.
• D. Risk for injury.

Correct answer: D

Rationale: The correct answer is 'Risk for injury.' In a client with dementia who is disoriented, wandering, and experiencing sleep disturbances, the priority nursing problem is the risk for injury. Disorientation and wandering behavior can lead to accidents, falls, or other harmful situations, making it crucial for the nurse to address the safety concerns first to prevent any potential harm to the client.

2. A client receiving total parenteral nutrition (TPN) through a central line suddenly develops dyspnea, chest pain, and a drop in blood pressure. What should the nurse do first?

• A. Stop the TPN infusion.
• B. Notify the healthcare provider.
• C. Place the client in Trendelenburg position.
• D. Administer oxygen at 2 liters/minute.

Correct answer: C

Rationale: Placing the client in Trendelenburg position should be the initial action as it can help manage a suspected air embolism, a potential complication of TPN administration. This position helps trap air in the apex of the atrium, reducing the risk of air reaching the pulmonary circulation and causing further harm. Once the client is in a safe position, further actions such as stopping the TPN infusion, notifying the healthcare provider, and administering oxygen can be taken as appropriate.

3. An 89-year-old male client complains to the nurse that people are whispering behind his back and mumbling when they talk to him. What age-related condition is likely to be occurring with this client?

• A. Delirium
• B. Presbyopia
• C. Presbycusis
• D. Cerebral dysfunction

Correct answer: C

Rationale: The correct answer is C, Presbycusis. Presbycusis is age-related hearing loss that often affects the ability to hear high-pitched sounds, making speech appear mumbled. This condition is common in older adults and can lead to difficulties in understanding conversations, as in the case of the client complaining about people whispering and mumbling.

4. An elderly female client comes to the clinic for a regular check-up. The client tells the nurse that she has increased her daily doses of acetaminophen (Tylenol) for the past month to control joint pain. Based on this client's comment, what previous lab values should the nurse compare with today's lab report?

• A. Look at last quarter's hemoglobin and hematocrit to assess for dehydration.
• B. Look for an increase in today's LDH compared to the previous one to assess for possible liver damage.
• C. Expect to find an increase in today's APTT compared to last quarter's due to bleeding.
• D. Determine if there is a decrease in serum potassium due to renal compromise.

Correct answer: B

Rationale: When a client increases their daily doses of acetaminophen for joint pain, it raises concerns about possible liver damage due to acetaminophen overdose. LDH (Lactate Dehydrogenase) levels can indicate liver function, so comparing today's levels with previous ones can help assess for liver damage caused by acetaminophen overuse.

5. A client who participates in a health maintenance organization (HMO) needs a bone marrow transplant for the treatment of breast cancer. The client tells the nurse that she is concerned that her HMO may deny her claim. What action by the nurse best addresses the client's need at this time?

• A. Have the client's healthcare provider write a letter to the HMO explaining the need for the transplant.
• B. Help the client place a call to the HMO to seek information about limitations of coverage.
• C. Encourage the client to contact a lawyer to file a lawsuit against the HMO if necessary.
• D. Have the social worker contact the state board of insurance to register a complaint against the HMO.

Correct answer: B

Rationale: The best action for the nurse to take in this situation is to help the client directly contact the HMO to seek information about limitations of coverage. This approach addresses the client's immediate concerns and clarifies the situation, enabling the client to understand the coverage and potential outcomes regarding the bone marrow transplant. Choice A is not the best option as having the healthcare provider write a letter may not provide immediate clarification on coverage. Choice C is inappropriate as legal action should be considered as a last resort, and choice D involving the state board of insurance is not necessary at this initial stage of addressing the client's concern.

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