Nursing Elites

1. A client with which of the following conditions is at risk for developing a high ammonia level?

• A. renal failure
• B. psoriasis
• C. lupus
• D. cirrhosis

Correct answer: D

Rationale: A client with cirrhosis is at risk for developing a high ammonia level due to impaired liver function. The liver normally converts ammonia into urea for excretion. In cirrhosis, this process is compromised, leading to elevated ammonia levels in the blood. Renal failure, psoriasis, and lupus do not typically cause high ammonia levels. Renal failure affects kidney function, while psoriasis and lupus are autoimmune conditions that do not directly impact ammonia metabolism.

2. The nurse is teaching a teenage female about preventing the transmission of genital herpes. Which of the following statements should the nurse include?

• A. "Do not sit on toilet seats without protection."?
• B. "Oral sex can transmit the virus."?
• C. "This infection can be transmitted via intercourse even when you do not feel ill."?
• D. "Try to drink lots of fluids after sex to flush the reproductive tract."?

Correct answer: C

Rationale: Genital herpes can be transmitted through oral, genital, and anal sex. It's crucial to understand that the infection can be spread through intercourse even when symptoms are not present. Option A is incorrect because genital herpes is not transmitted through toilet seats. Option B is correct as oral sex can transmit the virus. Option D is incorrect as drinking fluids after sex does not prevent the transmission of genital herpes.

3. What action should the emergency triage nurse take upon receiving the history that a client has a severe cough, fever, night sweats, and body wasting?

• A. Place the client in isolation until further assessment is completed.
• B. Seclude the client from other clients and visitors.
• C. Perform no intervention until test results confirm a diagnosis.
• D. Don personal protective equipment immediately.

Correct answer: B

Rationale: The correct action for the emergency triage nurse to take upon receiving the history that a client has a severe cough, fever, night sweats, and body wasting is to seclude the client from other clients and visitors. These symptoms are suggestive of tuberculosis, a highly infectious disease. By secluding the client, the nurse can prevent the potential spread of the infection to others. Donning personal protective equipment, including gown, gloves, and a mask, is crucial when providing care to the client, but the immediate priority is to prevent the spread of infection by isolating the client. Placing the client in isolation until further assessment is completed ensures that the client is kept away from others until a proper diagnosis and treatment plan can be established, reducing the risk of transmission. Performing no intervention until test results confirm a diagnosis is inappropriate as immediate isolation is necessary in suspected cases of highly infectious diseases like tuberculosis.

4. Following an automobile accident that caused a head injury to an adult client, the nurse observes that the client sleeps for long periods of time. The nurse determines that the client has experienced injury to the:

• A. hypothalamus.
• B. thalamus.
• C. cortex.
• D. medulla.

Correct answer: A

Rationale: The hypothalamus is responsible for regulating sleep patterns among other functions. Injury to the hypothalamus can disrupt the sleep-wake cycle, leading to excessive sleepiness or changes in sleep patterns. Choices B, C, and D are incorrect as they do not primarily control sleep regulation. The thalamus is involved in relaying sensory information, the cortex is responsible for higher brain functions, and the medulla controls vital functions such as heartbeat and breathing.

5. Which of the following might be an appropriate nursing diagnosis for an epileptic client?

• A. Dysreflexia
• B. Risk for Injury
• C. Urinary Retention
• D. Unbalanced Nutrition

Correct answer: B

Rationale: The correct answer is 'Risk for Injury.' Epileptic clients are at risk for injury due to complications of seizure activity, such as falls that could lead to head trauma. 'Dysreflexia' is not typically associated with epilepsy but rather with spinal cord injury. 'Urinary Retention' is not a common nursing diagnosis for epileptic clients unless specifically indicated. 'Unbalanced Nutrition' may not be a priority nursing diagnosis compared to the immediate risk of injury in epileptic clients.

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