Nursing Elites

1. What assessments should the nurse prioritize for a client with portal hypertension admitted to the medical floor?

• A. Assessment of blood pressure and evaluation for headaches and visual changes
• B. Assessment for signs and symptoms of venous thromboembolism
• C. Daily weights and measurement of abdominal girth
• D. Monitoring blood glucose every 4 hours

Correct answer: C

Rationale: In portal hypertension, daily weights and measurement of abdominal girth are crucial assessments to monitor fluid retention and ascites. These assessments help in evaluating the effectiveness of treatment and identifying any worsening of the condition, guiding appropriate interventions. Monitoring blood pressure and assessing for symptoms like headaches and visual changes may be important but are not the priority in this case. Assessing for signs and symptoms of venous thromboembolism is relevant in some situations but not directly related to the primary concerns of portal hypertension.

2. A client with a history of chronic heart failure is experiencing severe shortness of breath and has pink, frothy sputum. Which action should the nurse take first?

• A. Administer morphine sulfate.
• B. Place the client in a high Fowler's position.
• C. Initiate continuous ECG monitoring.
• D. Prepare the client for intubation.

Correct answer: B

Rationale: In a client with chronic heart failure experiencing severe shortness of breath and pink, frothy sputum, the priority action for the nurse is to place the client in a high Fowler's position. This position helps improve lung expansion, ease breathing, and enhance oxygenation by reducing venous return and decreasing preload on the heart. It is crucial to address the client's respiratory distress promptly before considering other interventions. Administering morphine sulfate (choice A) may be appropriate later to relieve anxiety and reduce the work of breathing, but positioning is the priority. Continuous ECG monitoring (choice C) and preparing for intubation (choice D) are important but secondary to addressing the respiratory distress and optimizing oxygenation.

3. In acute pancreatitis, a client experiencing severe abdominal pain should have which enzyme level closely monitored?

• A. Serum amylase.
• B. Serum sodium.
• C. Serum calcium.
• D. Serum potassium.

Correct answer: A

Rationale: In acute pancreatitis, serum amylase levels should be closely monitored. Elevated serum amylase levels are a key diagnostic marker for acute pancreatitis, aiding in the assessment and management of the patient's condition. Monitoring serum sodium, calcium, or potassium levels is not typically associated with acute pancreatitis and would not provide relevant information for this specific condition.

4. 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.

5. A 45-year-old woman with occasional indigestion has had episodes of chest pain and dysphagia to both solids and liquids. An upper GI series and EGD fail to disclose any structural abnormalities. What is the most appropriate initial therapy?

• A. Sucralfate
• B. Proton pump inhibitor
• C. Prokinetic agent
• D. Benzodiazepine

Correct answer: B

Rationale: The patient's symptoms of chest pain and dysphagia suggest esophageal spasm, often related to underlying gastroesophageal reflux. The initial therapy should focus on acid suppression. Proton pump inhibitors are the preferred choice to reduce acid production and alleviate symptoms. If proton pump inhibitors are ineffective, other options like smooth muscle relaxants or antidepressants may be considered. A Heller myotomy is not indicated in this case as the patient does not have achalasia.

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