Nursing Elites

1. During the initial assessment of a client with a history of substance abuse admitted for detoxification, which intervention is most important?

• A. Obtain a detailed substance use history.
• B. Establish a trusting nurse-client relationship.
• C. Evaluate the client's physical health status.
• D. Determine the client's readiness for change.

Correct answer: C

Rationale: Assessing the client's physical health status is the most critical intervention during the initial assessment of a client with a history of substance abuse admitted for detoxification. This evaluation helps identify and address any immediate health risks, such as withdrawal symptoms or medical complications, to ensure the client's safety and well-being during the detoxification process. Option A, obtaining a detailed substance use history, is important but not the most critical initially. Option B, establishing a trusting nurse-client relationship, is important but assessing physical health takes precedence. Option D, determining the client's readiness for change, is valuable but assessing physical health for immediate risks is the priority.

2. What is/are the possible cause(s) of acute pancreatitis in this patient?

• A. HIV
• B. Cytomegalovirus
• C. Dideoxyinosine (ddI)
• D. Pentamidine

Correct answer: B

Rationale: This patient presents with symptoms and lab findings consistent with acute pancreatitis. Cytomegalovirus is a common viral infection associated with pancreatitis. In patients with AIDS, the pancreas can be affected by various infections (e.g., cryptococcus, Mycobacterium tuberculosis, candida, Toxoplasma gondii) and medications (such as ddI, pentamidine, trimethoprim/sulfamethoxazole, metronidazole) can also lead to acute pancreatitis. While HIV infection predisposes individuals to various opportunistic infections, in this case, the most likely cause of the acute pancreatitis is cytomegalovirus infection.

3. A patient with severe pain is prescribed morphine sulfate. What is the most important side effect for the nurse to monitor?

• A. Diarrhea
• B. Hypertension
• C. Respiratory depression
• D. Increased urine output

Correct answer: C

Rationale: When a patient is prescribed morphine sulfate, the most critical side effect for the nurse to monitor is respiratory depression. Morphine can suppress the respiratory drive, leading to inadequate ventilation and potentially life-threatening consequences. Monitoring the patient's respiratory status closely is essential to promptly identify and manage any signs of respiratory depression.

4. A client with severe anemia is being treated with a blood transfusion. Which assessment finding indicates a transfusion reaction?

• A. Elevated blood pressure.
• B. Fever and chills.
• C. Increased urine output.
• D. Bradycardia.

Correct answer: B

Rationale: Fever and chills are classic signs of a transfusion reaction. These symptoms indicate that the body is having a response to the transfused blood, possibly due to incompatibility or an immune reaction. Elevated blood pressure (choice A) is not a typical sign of a transfusion reaction. Increased urine output (choice C) and bradycardia (choice D) are also not characteristic signs of a transfusion reaction. It is crucial to recognize symptoms of a transfusion reaction promptly to prevent further complications and ensure appropriate management.

5. Why is morphine administered to a patient with a myocardial infarction (MI)?

• A. To reduce pain.
• B. To decrease anxiety.
• C. To reduce cardiac workload.
• D. To increase respiratory rate.

Correct answer: C

Rationale: Morphine is administered to a patient with a myocardial infarction (MI) primarily to reduce cardiac workload. By reducing preload and afterload, morphine helps improve oxygenation to the heart muscle. This decrease in workload on the heart can alleviate symptoms and reduce strain on the heart muscle during an MI. Choices A and B are incorrect because the primary goal of administering morphine in this context is not pain relief or anxiety reduction. Choice D is incorrect as morphine does not aim to increase respiratory rate but rather to address the cardiac workload.

Similar Questions