Nursing Elites

1. While assessing a patient in the ICU, a nurse observes signs of a weak pulse, quick respiration, acetone breath, and nausea. Which of the following conditions is most likely occurring?

• A. Hypoglycemic patient
• B. Hyperglycemic patient
• C. Cardiac arrest
• D. End-stage renal failure

Correct answer: B

Rationale: The correct answer is a hyperglycemic patient. The signs described - weak pulse, quick respiration, acetone breath, and nausea - are indicative of hyperglycemia. A hypoglycemic patient would typically present with different signs such as pale skin, sweating, and confusion. Cardiac arrest would manifest with sudden loss of heart function and consciousness, not the signs described. End-stage renal failure would present with symptoms related to kidney dysfunction like edema, fatigue, and changes in urine output, which are not mentioned in the scenario.

2. Paula is a 32-year-old woman seeking evaluation and treatment for major depressive symptoms. A major nursing priority during the assessment process includes which of the following?

• A. meaning of current stressors
• B. possibility of self-harm
• C. motivation to participate in treatment
• D. presence of alcohol or other drug use

Correct answer: B

Rationale: The correct answer is to consider the possibility of self-harm during the assessment process. This is crucial because unless the client is first assessed for self-harm or suicide potential, the necessary degree of vigilance in the client's environment may not be observed. While understanding the meaning of current stressors is important for treatment planning, ensuring the client's safety takes precedence. Motivation to participate in treatment and the presence of alcohol or other drug use are also important aspects to assess but ensuring the client's safety is the top priority in this scenario.

3. Which of the following terms refers to soft tissue injury caused by blunt force?

• A. contusion
• B. strain
• C. sprain
• D. dislocation

Correct answer: A

Rationale: A contusion is a soft tissue injury caused by blunt force. It is an injury that does not break the skin, caused by a blow, and characterized by swelling, discoloration, and pain. The immediate application of cold might limit the development of a contusion. A strain is a muscle pull from overuse, overstretching, or excessive stress. A sprain is caused by a wrenching or twisting motion. A dislocation is a condition where the articular surfaces of the bones forming a joint are no longer in anatomical contact. Therefore, the correct answer is 'contusion' as it specifically relates to soft tissue injury caused by blunt force.

4. What should the nurse do while caring for a client with an eating disorder?

• A. Encourage the client to cook for others
• B. Weigh the client daily and keep a journal
• C. Restrict access to mirrors
• D. Monitor food intake and behavior for one hour after meals

Correct answer: D

Rationale: The correct answer is to monitor food intake and behavior for one hour after meals. This is crucial in caring for a client with an eating disorder as it helps in assessing any immediate risks related to the disorder. Option A is incorrect as it may trigger additional stress for the client and distract from the main focus of managing the disorder. Option B, weighing the client daily, could lead to an unhealthy focus on weight and potentially worsen the client's mental health. Option C, restricting access to mirrors, although it may be beneficial for body image concerns, does not directly address the core issue of monitoring food intake and behavior, which is essential in managing eating disorders.

5. Which of the following is not a primary function of the kidneys?

• A. blood pressure control
• B. vitamin D activation
• C. erythropoietin production
• D. reabsorption of waste products

Correct answer: D

Rationale: The correct answer is reabsorption of waste products because the kidneys excrete waste products rather than reabsorbing them. Choices A, B, and C are indeed primary functions of the kidneys. The kidneys play a crucial role in regulating blood pressure, activating vitamin D, and producing erythropoietin, which stimulates red blood cell production. Therefore, the primary role of the kidneys is to filter blood, remove waste products, regulate fluid balance, and maintain electrolyte balance.

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