Nursing Elites

1. A client with amphetamine toxicity and sensory overload is being cared for by a nurse. Which intervention should the nurse implement?

• A. Immediately conduct a thorough assessment.
• B. Encourage visitors to distract the client.
• C. Provide a private room and limit stimulation.
• D. Speak softly to the client.

Correct answer: C

Rationale: The most appropriate intervention for a client with amphetamine toxicity and sensory overload is to provide a private room and limit stimulation. This approach helps reduce external stimuli, which can exacerbate sensory overload, and creates a calming environment for the client. Encouraging visitors to distract the client may worsen sensory overload by adding more stimulation. Speaking softly, rather than at a higher volume, is more suitable to help maintain a calm environment. Therefore, the correct choice is to provide a private room and limit stimulation (option C) in this scenario.

2. A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit, and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess?

• A. Bounding pulse
• B. Decreased blood pressure
• C. Dry mucous membranes
• D. Weak pulse

Correct answer: A

Rationale: A bounding pulse is indicative of fluid volume excess. In this case, the client's weight gain and edematous ankles already suggest fluid volume overload. A bounding pulse occurs due to increased blood volume and pressure. Choices B, C, and D are not indicative of fluid volume excess. Decreased blood pressure, dry mucous membranes, and weak pulse are more commonly associated with conditions such as dehydration or hypovolemia, where there is a decrease in fluid volume rather than an excess.

3. During an admission history, a client tells a nurse that she is under a lot of stress. Which of the following physiological responses should the nurse expect to increase as a result of stress?

• A. Blood glucose - a common stress response.
• B. Intestinal peristalsis - should decrease due to stress.
• C. Peripheral blood vessels diameter - can vary in response to stress.
• D. Urine output - may vary but not a typical stress response.

Correct answer: A

Rationale: The correct answer is A. Stress typically increases blood glucose levels due to the release of stress hormones like cortisol and adrenaline. Elevated blood glucose helps provide energy for the body to cope with the stressful situation. Choice B is incorrect because intestinal peristalsis, the movement of the intestines, is more likely to decrease under stress due to the 'fight or flight' response. Choice C is incorrect as peripheral blood vessels' diameter may vary in response to stress, with both constriction and dilation possible. Choice D is incorrect as urine output may increase or decrease depending on individual differences and the specific stress response, but it is not a typical or direct physiological response to stress.

4. An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings through a gastrostomy tube. What is the best client position for the administration of bolus tube feedings?

• A. Prone.
• B. Fowler's.
• C. Sims'.
• D. Supine.

Correct answer: B

Rationale: The correct answer is Fowler's position. Placing the client in Fowler's position, with the head of the bed elevated to 45-60 degrees, reduces the risk of aspiration during bolus enteral feedings by facilitating the flow of the feeding into the stomach. Prone position (choice A) is lying face down, which is not suitable for feeding. Sims' position (choice C) is a side-lying position used for rectal examinations or enemas, not for feeding. Supine position (choice D) is lying flat on the back and is not optimal for reducing the risk of aspiration during bolus tube feedings.

5. A nurse in a provider’s office is collecting data from the caregiver of a 12-month-old infant who asks if the child is old enough for toilet training. Following an educational session with the nurse, the client agrees to postpone toilet training until the child is older. Learning has occurred in which of the following domains?

• A. Cognitive
• B. Affective
• C. Psychomotor
• D. Kinesthetic

Correct answer: B

Rationale: The correct answer is B: Affective. The caregiver’s decision to postpone toilet training indicates a change in feelings or attitudes, which falls under the affective domain of learning. The affective domain relates to emotions, values, and attitudes. In this scenario, the caregiver's willingness to delay toilet training due to new information reflects a shift in attitude impacted by the educational session provided by the nurse. Choices A, C, and D are incorrect. The cognitive (choice A) domain involves intellectual skills and knowledge, the psychomotor (choice C) domain involves physical skills, and kinesthetic (choice D) is often used interchangeably with the psychomotor domain, which focuses on physical movement and coordination.

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