Nursing Elites

1. A client with cirrhosis of the liver is experiencing pruritus. Which intervention should the nurse implement to help relieve the client's symptoms?

• A. Administer acetaminophen (Tylenol).
• B. Apply lotion to the skin.
• C. Encourage a high-protein diet.
• D. Provide a warm bath.

Correct answer: B

Rationale: Pruritus is a common symptom in clients with cirrhosis due to bile salts accumulating in the skin. Applying lotion to the skin helps soothe the itching and can prevent skin breakdown. Acetaminophen can worsen liver damage in clients with cirrhosis as it is metabolized in the liver. Encouraging a high-protein diet is not directly related to relieving pruritus. Providing a warm bath may further dry the skin, exacerbating the itching. Therefore, the most appropriate intervention to help relieve pruritus in a client with cirrhosis is to apply lotion to the skin.

2. A 50-year-old man presents with fatigue, arthralgia, and darkening of the skin. Laboratory tests reveal elevated liver enzymes and high serum ferritin levels. What is the most likely diagnosis?

• A. Wilson's disease
• B. Hemochromatosis
• C. Alpha-1 antitrypsin deficiency
• D. Autoimmune hepatitis

Correct answer: B

Rationale: The symptoms of fatigue, arthralgia, and skin darkening, along with elevated liver enzymes and high serum ferritin levels, are characteristic of hemochromatosis, a condition characterized by iron overload. In hemochromatosis, excess iron is deposited in various organs, including the liver, leading to symptoms such as fatigue, joint pain, and skin pigmentation changes. The elevated liver enzymes and high serum ferritin levels seen in this patient further support the diagnosis of hemochromatosis.

3. Which assessment finding indicates a client's readiness to leave the nursing unit for a bronchoscopy?

• A. Client denies allergies to contrast media.
• B. Skin prep to insertion site completed.
• C. On-call sedation administered.
• D. Oxygen at 2 L/minute via nasal cannula.

Correct answer: C

Rationale: Administering on-call sedation is crucial before a bronchoscopy to ensure the client is comfortable and adequately prepared for the procedure. Sedation helps reduce anxiety, discomfort, and ensures the client remains still during the bronchoscopy, enabling the healthcare provider to perform the procedure effectively.

4. The client with newly diagnosed hypertension is being taught about lifestyle modifications. Which recommendation should be made?

• A. Increase your intake of saturated fats.
• B. Limit your alcohol intake to two drinks per day.
• C. Engage in at least 150 minutes of moderate exercise per week.
• D. Use table salt liberally to season your food.

Correct answer: C

Rationale: Engaging in at least 150 minutes of moderate exercise per week is a key lifestyle modification recommended for individuals with hypertension. Regular exercise helps manage blood pressure, improve cardiovascular health, and overall well-being. It is important for the client to adopt a healthy lifestyle to control hypertension and reduce the risk of complications.

5. The mental health nurse observes that a female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them. Which nursing action will promote trust?

• A. Explain that distrust is related to feeling anxious.
• B. Initiate short, frequent contacts with the client.
• C. Explain that these beliefs are related to her illness.
• D. Offer to keep the belongings at the nurse's desk.

Correct answer: B

Rationale: Initiating short, frequent contacts with the client is the most appropriate action to promote trust. This approach helps build trust and rapport, addressing the client's need for security. By maintaining regular contact, the nurse can provide reassurance and support, which can help alleviate the client's anxiety related to her delusional beliefs. Choice A does not directly address the client's need for trust and security. Choice C focuses on the client's illness but does not actively address building trust. Choice D, offering to keep the belongings at the nurse's desk, may not be well-received by the client and could potentially worsen her anxiety and distrust.

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