Nursing Elites

1. A male client with schizophrenia is jerking his neck and smacking his lips. Which finding indicates to the nurse that he is experiencing an irreversible side effect of antipsychotic agents?

• A. Cramping muscular pain
• B. Worming movements of the tongue
• C. Decreased tendon reflexes
• D. Dry oral mucous membranes

Correct answer: B

Rationale: The correct answer is B: Worming movements of the tongue. Worming movements of the tongue, known as tardive dyskinesia, are an irreversible side effect of antipsychotic medications. Tardive dyskinesia is characterized by involuntary, repetitive movements of the tongue, lips, face, trunk, and extremities. Cramping muscular pain (Choice A) is more indicative of dystonia, an extrapyramidal side effect that can be treated effectively with antiparkinsonian medications. Decreased tendon reflexes (Choice C) are not typically associated with irreversible side effects of antipsychotic agents. Dry oral mucous membranes (Choice D) are not specific to irreversible side effects of antipsychotic medications.

2. A client with multiple sclerosis is experiencing scotomas (blind spots), which are limiting peripheral vision. What intervention should the nurse include in this client's plan of care?

• A. Encourage the use of corrective lenses during the day
• B. Practice visual exercises that focus on a still object
• C. Alternate an eye patch from eye every 2 hours
• D. Teach techniques for scanning the environment

Correct answer: D

Rationale: The correct intervention for a client with multiple sclerosis experiencing scotomas and limited peripheral vision is to teach techniques for scanning the environment. This intervention helps the client compensate for vision loss by learning how to scan and explore their surroundings effectively. Encouraging the use of corrective lenses may not address the issue of scotomas, and visual exercises focusing on a still object may not enhance peripheral vision. Alternating an eye patch every 2 hours is not typically indicated for scotomas in multiple sclerosis, making it an incorrect choice.

3. Which client is at the greatest risk for developing delirium?

• A. An adult client who cannot sleep due to constant pain
• B. An older client who attempted suicide 1 month ago
• C. A young adult who takes antipsychotic medications twice a day
• D. A middle-aged woman who uses a tank for supplemental oxygen

Correct answer: B

Rationale: The correct answer is B because older adults are at higher risk for delirium, especially following a recent suicide attempt, which can be a significant stressor. Choice A is less likely to develop delirium solely due to difficulty sleeping; delirium is more complex and multifactorial. Choice C, a young adult taking antipsychotic medications, may be at risk for other conditions but not necessarily delirium. Choice D, a middle-aged woman using supplemental oxygen, is not directly linked to an increased risk of delirium compared to the older client who recently attempted suicide.

4. A client with acute renal failure (ARF) is admitted for uncontrolled type 1 diabetes mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. Which intervention is the most important for the nurse to include in this client’s plan of care?

• A. Monitor the client’s cardiac activity via telemetry.
• B. Maintain venous access with an infusion of normal saline.
• C. Assess glucose levels via finger stick every 4 to 6 hours.
• D. Evaluate hourly urine output for the return of normal renal function.

Correct answer: A

Rationale: Monitoring cardiac activity is crucial in this scenario because hyperkalemia can lead to serious cardiac dysrhythmias, which can be life-threatening. Regular monitoring of the client’s cardiac activity via telemetry allows for early detection of any potential cardiac complications. Maintaining venous access with a normal saline infusion is important for hydration but does not address the immediate risk of cardiac dysrhythmias posed by hyperkalemia. Assessing glucose levels is essential in diabetes management but is not the priority when dealing with hyperkalemia-induced cardiac risks. Evaluating hourly urine output for the return of normal renal function is important in ARF but is not as urgent as monitoring the client's cardiac activity in the context of hyperkalemia.

5. The practical nurse (PN) is assigned to work with three registered nurses (RN) who are caring for neurologically compromised clients. The client with which change in status is best to assign to the PN?

• A. Diabetic ketoacidosis whose Glasgow Coma Scale score changed from 10 to 7
• B. Subdural hematoma whose blood pressure changed from 150/80 mmHg to 170/60 mmHg
• C. Myxedema coma whose blood pressure changed from 80/50 mmHg to 70/40 mmHg
• D. Viral meningitis whose temperature changed from 101° F (38.3 C) to 102° F (38.9C)

Correct answer: D

Rationale: The correct answer is D because viral meningitis with a slight increase in temperature is less acute and complex compared to the other conditions. This change in temperature does not indicate a critical or urgent situation requiring immediate attention or intervention beyond the scope of a practical nurse. Choices A, B, and C present more significant changes in health status such as a decrease in Glasgow Coma Scale score, an increase in intracranial pressure indicated by blood pressure changes, and a significant drop in blood pressure, respectively. These changes require closer monitoring and intervention by registered nurses due to the higher acuity and complexity of care needed for these conditions.

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