Nursing Elites

1. A client with a history of alcoholism is admitted with confusion, ataxia, and nystagmus. Which nursing intervention is a priority for this client?

• A. Monitor for signs of alcohol withdrawal.
• B. Administer thiamine as prescribed.
• C. Provide a quiet environment to reduce confusion.
• D. Initiate fall precautions.

Correct answer: B

Rationale: The correct answer is B: Administer thiamine as prescribed. Administering thiamine is crucial in clients with a history of alcoholism to prevent Wernicke's encephalopathy, which is characterized by confusion, ataxia, and nystagmus. Monitoring for signs of alcohol withdrawal (choice A) is important but not the priority. Providing a quiet environment (choice C) and initiating fall precautions (choice D) are important interventions, but administering thiamine takes precedence due to the risk of Wernicke's encephalopathy.

2. A 10-year-old who has terminal brain cancer asks the nurse, 'What will happen to my body when I die?' How should the nurse respond?

• A. Your mother and father will be here soon. Talk to them about that.'
• B. Why do you want to know about what will happen to your body when you die?'
• C. The heart will stop beating and you will stop breathing.'
• D. Are you concerned about where your spirit will go?'

Correct answer: C

Rationale: The correct response when a terminally ill child asks about what will happen to their body when they die is to provide a truthful and straightforward answer. Choice C, 'The heart will stop beating and you will stop breathing,' is the best response because it offers a simple and honest explanation without delving into spiritual or emotional aspects that may be confusing or distressing to the child. Choices A and D deflect the question and do not address the child's inquiry directly. Choice B, 'Why do you want to know about what will happen to your body when you die?' may come across as dismissive or evasive, rather than providing the clear information the child is seeking.

3. For the past 24 hours, an antidiarrheal agent, diphenoxylate, has been administered to a bedridden, older client with infectious gastroenteritis. Which finding requires the nurse to take further action?

• A. Tented skin turgor
• B. Decreased bowel sounds
• C. Persistent diarrhea
• D. Dehydration

Correct answer: A

Rationale: The correct answer is A. Tented skin turgor is a sign of dehydration, which can be exacerbated by the use of antidiarrheals in clients with gastroenteritis. In dehydration, the skin loses its elasticity and becomes less resilient when pinched. Therefore, the nurse should take immediate action upon noticing tented skin turgor to prevent further complications. Choices B, C, and D are incorrect because decreased bowel sounds, persistent diarrhea, and dehydration are expected findings in a client with gastroenteritis who has been administered an antidiarrheal agent.

4. A client with chronic liver disease is admitted with ascites and jaundice. Which assessment finding is most concerning?

• A. Enlarged spleen
• B. Increased abdominal girth
• C. Yellowing of the skin
• D. Confusion and altered mental status

Correct answer: D

Rationale: Confusion and altered mental status are concerning in a client with chronic liver disease, as they may indicate hepatic encephalopathy, a serious complication that requires immediate intervention. Enlarged spleen (choice A) can be a common finding in liver disease due to portal hypertension but may not be as acute as hepatic encephalopathy. Increased abdominal girth (choice B) is typically seen in ascites, which is already present in this client. Yellowing of the skin (choice C) is a manifestation of jaundice, also a known symptom in liver disease but not as acute as confusion and altered mental status.

5. The charge nurse of the critical care unit informed at the beginning of the shift that a less than optimal number of registered nurses would be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse?

• A. A 34-year-old admitted today after an emergency appendectomy who has a peripheral intravenous catheter and a Foley catheter.
• B. A 48-year-old marathon runner with a central venous catheter experiencing nausea and vomiting due to electrolyte disturbance following a race.
• C. A 63-year-old chain smoker with chronic bronchitis receiving oxygen via nasal cannula and a saline-locked peripheral intravenous catheter.
• D. An 82-year-old client with Alzheimer's disease and a newly fractured femur with a Foley catheter and soft wrist restraints applied.

Correct answer: D

Rationale: The 82-year-old client with Alzheimer's disease and a newly fractured femur should receive the most care hours by a registered nurse because they are at the highest risk for injury and complications. The client's age, diagnosis of Alzheimer's disease, and the presence of a newly fractured femur along with the Foley catheter and wrist restraints indicate a need for close monitoring and care. Choice A is less critical as the client is stable post-appendectomy. Choice B, though experiencing symptoms, is not at the same level of risk as the client in Choice D. Choice C, while requiring oxygen support, does not have the same level of acuity and complexity as the client in Choice D.

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