Nursing Elites

1. A client with a history of diabetes mellitus is admitted with hypoglycemia. Which finding requires immediate intervention?

• A. Blood glucose of 60 mg/dL.
• B. Heart rate of 100 beats per minute.
• C. Tremors.
• D. Diaphoresis.

Correct answer: C

Rationale: In a client with a history of diabetes mellitus admitted with hypoglycemia, the finding that requires immediate intervention is tremors. Tremors can indicate severe hypoglycemia, which needs prompt attention to prevent complications such as seizures or loss of consciousness. While a blood glucose level of 60 mg/dL is low, the presence of tremors signifies a more urgent situation. A heart rate of 100 beats per minute and diaphoresis are common physiological responses to hypoglycemia and do not necessarily require immediate intervention unless other severe symptoms are present.

2. A client with a history of seizures is admitted with status epilepticus. Which medication should the nurse prepare to administer?

• A. Phenytoin (Dilantin)
• B. Diazepam (Valium)
• C. Lorazepam (Ativan)
• D. Carbamazepine (Tegretol)

Correct answer: C

Rationale: In the management of status epilepticus, the initial medication of choice is a benzodiazepine to rapidly terminate the seizure activity. Lorazepam (Ativan) is preferred over Diazepam (Valium) due to its longer duration of action and lower risk of respiratory depression. Phenytoin (Dilantin) and Carbamazepine (Tegretol) are not the first-line agents for the acute treatment of status epilepticus, making them incorrect choices in this scenario.

3. The healthcare provider is caring for a client with a urinary tract infection. Which finding requires immediate intervention?

• A. Dysuria.
• B. Hematuria.
• C. Fever.
• D. Urinary frequency.

Correct answer: C

Rationale: Fever can indicate a severe infection, such as pyelonephritis, in a client with a urinary tract infection and requires immediate intervention. Hematuria and dysuria are common symptoms of a urinary tract infection but may not always require immediate intervention unless severe. Urinary frequency is also a common symptom and does not indicate the severity of the infection as fever does.

4. A public health nurse is planning a vaccination clinic for a rural community. Which vaccine should the nurse prioritize for adults in this area?

• A. hepatitis A
• B. influenza
• C. varicella
• D. measles, mumps, rubella (MMR)

Correct answer: B

Rationale: The correct answer is 'B: influenza.' Influenza vaccination is crucial for adults, particularly in rural areas where access to healthcare may be limited. Influenza can cause serious illness and complications, and vaccination helps protect individuals and prevent the spread of the virus. While vaccines for hepatitis A, varicella, and measles, mumps, rubella (MMR) are important, prioritizing influenza vaccination in this scenario is essential due to its seasonal prevalence and potential impact on public health. Hepatitis A and varicella vaccines are also important but may not be as immediately critical for this population. MMR vaccine is typically administered in childhood, so it is not the priority for adults in this scenario.

5. During a health assessment for a family with a history of cardiovascular disease, which family member should be prioritized for further evaluation and intervention?

• A. a 45-year-old father who smokes and has high cholesterol
• B. a 17-year-old daughter who is overweight and inactive
• C. a 50-year-old mother with a history of hypertension
• D. a 12-year-old son who has a normal weight and is active

Correct answer: A

Rationale: The 45-year-old father who smokes and has high cholesterol should be prioritized for further evaluation and intervention. He has multiple risk factors for cardiovascular disease, including smoking and high cholesterol, which significantly increase his risk. Addressing these modifiable risk factors is crucial in preventing cardiovascular events. The daughter (Choice B) and mother (Choice C) also have risk factors, but the father's combination of smoking and high cholesterol places him at higher immediate risk, demanding priority intervention. The 12-year-old son (Choice D) with a normal weight and an active lifestyle has a lower risk profile and does not require immediate intervention compared to the father.

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