Nursing Elites

1. A client with a history of alcohol abuse is admitted with acute pancreatitis. Which assessment finding requires immediate intervention?

• A. Amylase of 120 U/L.
• B. Lipase of 150 U/L.
• C. Calcium of 8.5 mg/dL.
• D. Temperature of 101°F (38.3°C).

Correct answer: D

Rationale: In a client with acute pancreatitis and a history of alcohol abuse, a temperature of 101°F (38.3°C) can indicate infection, which is a serious complication requiring immediate intervention. Elevated amylase and lipase levels are common in acute pancreatitis but do not directly indicate the need for urgent intervention. A calcium level of 8.5 mg/dL is within the normal range and does not require immediate action in this context.

2. A client who is taking clonidine (Catapres, Duraclon) reports drowsiness. Which additional assessment should the nurse make?

• A. How long has the client been taking the medication?
• B. Assess the client's dietary habits.
• C. Check for signs of infection.
• D. Evaluate the client's sleep pattern.

Correct answer: A

Rationale: The correct answer is A. When a client reports drowsiness while taking clonidine, the nurse should assess how long the client has been taking the medication. Drowsiness is a common side effect that can occur in the early weeks of treatment with clonidine. By understanding the duration of medication use, the nurse can determine if the drowsiness is a temporary effect that may decrease over time. Choices B, C, and D are incorrect because assessing the client's dietary habits, checking for signs of infection, or evaluating the client's sleep pattern would not directly address the drowsiness associated with clonidine use.

3. An elderly client with a history of falls is being discharged from the hospital. Which intervention should the home health nurse implement to reduce the client's risk of falling at home?

• A. Install grab bars in the bathroom
• B. Provide a walker for ambulation
• C. Educate the client on fall prevention strategies
• D. Refer the client to a physical therapist

Correct answer: A

Rationale: Installing grab bars in the bathroom is crucial to reducing the elderly client's risk of falling at home. Grab bars provide physical support and stability, especially in areas like the bathroom where slips and falls are common among older adults. While providing a walker for ambulation (Choice B) can assist with mobility, it may not directly address the environmental hazards at home. Educating the client on fall prevention strategies (Choice C) is important but may not be sufficient if the physical environment is not modified to reduce fall risks. Referring the client to a physical therapist (Choice D) may help improve strength and balance but does not directly address the immediate environmental risk of falling at home.

4. The healthcare professional is developing a program to educate parents on the importance of immunizations. Which topic should be prioritized?

• A. the benefits of immunizations
• B. the potential side effects of vaccines
• C. the immunization schedule
• D. ways to comfort children during vaccinations

Correct answer: A

Rationale: Prioritizing the benefits of immunizations is crucial in helping parents comprehend the significance of vaccines in safeguarding their children against preventable diseases. Understanding the positive impact of immunizations can alleviate concerns and misconceptions that parents may have, ultimately encouraging them to make informed decisions regarding their children's health. Discussing potential side effects (choice B) is important but should come after highlighting the benefits to avoid instilling unnecessary fear. While the immunization schedule (choice C) is essential information, it may be overwhelming if presented as the initial focus. Comforting children during vaccinations (choice D) is valuable but secondary to ensuring parents understand the benefits of immunizations.

5. The nurse is teaching a group of high school adolescents about safety associated with traumatic injuries. Which factor causing spinal cord injuries should the nurse discuss with the adolescents?

• A. motor vehicle accidents
• B. violent assault
• C. sports injuries
• D. falls

Correct answer: A

Rationale: The correct answer is A: motor vehicle accidents. Motor vehicle accidents are a significant cause of spinal cord injuries among adolescents due to the high impact forces involved. While violent assault, sports injuries, and falls can also lead to spinal cord injuries, statistics show that motor vehicle accidents are a leading cause in this age group. Educating adolescents about the risks and preventive measures related to motor vehicle accidents is crucial in promoting their safety and well-being.

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