Nursing Elites

1. A client with a head injury is admitted to the hospital. Which finding indicates a need for immediate intervention?

• A. Glasgow Coma Scale (GCS) score of 15.
• B. Pupils are equal and reactive to light.
• C. Client is drowsy but arousable.
• D. Client does not remember the events leading to the injury.

Correct answer: C

Rationale: In a client with a head injury, being drowsy but still arousable can be a sign of increased intracranial pressure, which necessitates immediate intervention. This presentation may indicate a deterioration in neurological status, requiring prompt assessment and management to prevent further complications. Choices A, B, and D are not indicative of an immediate need for intervention in this scenario. A Glasgow Coma Scale (GCS) score of 15 indicates the highest level of consciousness; pupils being equal and reactive to light suggest intact cranial nerve function, and memory loss about the injury event is common in head injuries and does not necessarily warrant immediate intervention.

2. Which annual screening should the nurse include when planning eye health programs at a preschool?

• A. visual acuity
• B. red light reflex
• C. conjunctivitis
• D. glaucoma

Correct answer: A

Rationale: The correct answer is A: visual acuity. Screening for visual acuity is essential in preschoolers to identify any vision issues early on, such as nearsightedness or farsightedness, which may require corrective lenses or other interventions. Red light reflex (choice B) is a method used to assess the eyes for abnormalities, but it is not typically included in routine preschool eye health screenings. Conjunctivitis (choice C) is an eye infection and not a screening test. Glaucoma (choice D) is a condition more commonly associated with adults and the elderly, making it less relevant for preschool eye health programs.

3. The healthcare provider is caring for a client with hypokalemia. Which assessment finding requires immediate intervention?

• A. Muscle weakness.
• B. Irregular heart rate.
• C. Increased urinary output.
• D. Decreased deep tendon reflexes.

Correct answer: D

Rationale: Decreased deep tendon reflexes are a critical finding in hypokalemia that indicates severe potassium deficiency affecting neuromuscular function. Immediate intervention is necessary to prevent life-threatening complications such as respiratory failure or cardiac arrhythmias. Muscle weakness, irregular heart rate, and increased urinary output are also associated with hypokalemia but do not pose the same level of urgency as decreased deep tendon reflexes.

4. The healthcare provider is caring for a client with diabetes insipidus. Which finding indicates that the treatment is effective?

• A. Urine output is decreased.
• B. Thirst is decreased.
• C. Weight loss is observed.
• D. Urine specific gravity is within the normal range.

Correct answer: D

Rationale: In diabetes insipidus, the body loses excessive amounts of water, leading to diluted urine with low specific gravity. Therefore, when the urine specific gravity is within the normal range, it indicates that the kidneys are properly concentrating urine, which is a sign of effective treatment for diabetes insipidus. Choices A, B, and C are incorrect because in diabetes insipidus, there is polyuria (excessive urination), persistent thirst due to fluid loss, and potential weight loss due to fluid imbalance, so these findings would not indicate effective treatment.

5. The client, who is 6 weeks pregnant, is being educated by the nurse on prenatal care. Which statement indicates that the client comprehends the nurse's instructions?

• A. I will increase my intake of vitamin C.
• B. I will avoid alcohol and tobacco.
• C. I will need to take folic acid supplements.
• D. I will avoid taking any medication without consulting my healthcare provider.

Correct answer: D

Rationale: The correct answer is D. During pregnancy, it is crucial to avoid taking any medication without consulting a healthcare provider to prevent harm to the developing fetus. Choices A, B, and C are important aspects of prenatal care but do not specifically address the potential risks associated with taking medications during pregnancy. Increasing intake of vitamin C (Choice A) is beneficial but does not address medication safety. Avoiding alcohol and tobacco (Choice B) is essential, but the question focuses on medication safety. Taking folic acid supplements (Choice C) is vital for neural tube development but does not cover the broader topic of medication safety.

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