Nursing Elites

1. A client with a diagnosis of Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?

• A. Comatose, breathing unlabored
• B. Glasgow Coma Scale 8, respirations regular
• C. Appears to be sleeping, vital signs stable
• D. Glasgow Coma Scale 13, no ventilator required

Correct answer: B

Rationale: The correct answer is B. A Glasgow Coma Scale of 8 with regular respirations accurately describes a non-responsive state with independent breathing. Choice A is incorrect because 'comatose' implies a deeper state of unconsciousness than what is described in the scenario. Choice C is inaccurate as the client is not merely sleeping but non-responsive. Choice D is incorrect as a Glasgow Coma Scale of 13 indicates a higher level of consciousness than what is presented in the scenario.

2. A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2°C (102°F), heart rate of 105/min, a soft tender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse’s priority?

• A. Temperature
• B. Menses overdue
• C. Soft tender abdomen
• D. Heart rate

Correct answer: A

Rationale: The correct answer is A: Temperature. A high temperature of 39.2°C (102°F) indicates a fever, which can be a sign of infection or another serious condition. Investigating the cause of the fever is a priority to address any underlying health issue promptly. Menses overdue (choice B) could be relevant but is not as urgent as addressing a fever. A soft tender abdomen (choice C) is important but may be a consequence of the underlying condition causing the fever. Heart rate (choice D) is also significant, but the priority here is to identify the cause of the fever.

3. A healthcare professional is screening several clients at a neighborhood health fair. Which of the following assessment findings is the priority for referral for further care?

• A. HR 105/min
• B. BMI 25 kg/m²
• C. BP 148/92
• D. Glucose 45 mg/dL

Correct answer: D

Rationale: The correct answer is D, 'Glucose 45 mg/dL.' Glucose level of 45 mg/dL indicates hypoglycemia, which is a critical condition requiring immediate attention to prevent complications like seizures, loss of consciousness, and even coma. Hypoglycemia can lead to serious adverse outcomes if not promptly addressed. Choices A, B, and C do not represent immediate life-threatening conditions and can be managed as part of routine care, unlike hypoglycemia which demands urgent intervention.

4. A client is to have mafenide (Sulfamylon) cream applied to burned areas. For which serious side effect of mafenide therapy should the LPN/LVN monitor this client?

• A. Curling ulcer
• B. Renal shutdown
• C. Metabolic acidosis
• D. Hemolysis of red blood cells

Correct answer: C

Rationale: Corrected Rationale: Metabolic acidosis is a serious side effect of mafenide therapy that should be closely monitored. Mafenide can lead to metabolic acidosis due to its inhibition of carbonic anhydrase, resulting in the accumulation of carbonic acid. Curling ulcer (Choice A) is a stress-related mucosal lesion that occurs in the duodenum, primarily due to severe burns, not directly related to mafenide therapy. Renal shutdown (Choice B) is not a common side effect of mafenide therapy. Hemolysis of red blood cells (Choice D) is not a recognized side effect of mafenide cream application.

5. A client is admitted with acute pyelonephritis. Which symptom should the nurse expect the client to report?

• A. Flank pain
• B. Pedal edema
• C. Hypotension
• D. Weight gain

Correct answer: A

Rationale: Flank pain is a classic symptom of acute pyelonephritis, which is a bacterial infection of the kidney. It occurs due to inflammation and irritation of the renal capsule, leading to pain in the flank region. Pedal edema (swelling in the feet and ankles) is more commonly associated with conditions like heart failure or kidney disease, not typically seen in acute pyelonephritis. Hypotension (low blood pressure) is a systemic symptom that may occur with severe infections but is not a specific hallmark of pyelonephritis. Weight gain is also not a typical symptom of acute pyelonephritis; instead, patients may experience weight loss due to decreased appetite and systemic effects of infection.

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