Nursing Elites

1. When collecting data from a client with posttraumatic stress disorder (PTSD), which of the following manifestations should the nurse expect?

• A. Amnesia
• B. Hypervigilance
• C. Hallucinations
• D. Severe agitation

Correct answer: B

Rationale: The correct manifestation to expect when collecting data from a client with PTSD is hypervigilance. Hypervigilance refers to increased alertness, which is a common symptom of PTSD. This heightened state of awareness is characterized by an exaggerated startle response, being easily startled, and constantly scanning the environment for potential threats. Amnesia (choice A) is not typically a primary manifestation of PTSD; it is more commonly associated with dissociative disorders. Hallucinations (choice C) involve perceiving things that are not present and are not typically a hallmark symptom of PTSD. Severe agitation (choice D) may occur in individuals with PTSD, but hypervigilance is a more specific and common manifestation associated with this disorder.

2. What is the correct intervention for a patient experiencing anaphylaxis?

• A. Administer epinephrine
• B. Provide oxygen
• C. Monitor airway
• D. All of the above

Correct answer: D

Rationale: In cases of anaphylaxis, all of the listed interventions are crucial for effective management. Administering epinephrine is the primary treatment to reverse the allergic reaction rapidly. Providing oxygen ensures adequate oxygenation to vital organs, and monitoring the airway is essential to prevent obstruction and maintain a clear air passage. Therefore, all three interventions are necessary in managing anaphylaxis. Choices A, B, and C are not individually sufficient to address all aspects of anaphylaxis, making the comprehensive approach of 'All of the above' the correct answer.

3. What should a healthcare provider monitor in a client with constipation?

• A. Monitor the client's bowel sounds every 4 hours
• B. Increase the client's activity to stimulate bowel movement
• C. Encourage the client to use a stool softener
• D. Encourage the client to rest in bed until constipation resolves

Correct answer: C

Rationale: Encouraging the client to use a stool softener is the appropriate intervention for constipation. Stool softeners help to soften the stool, making it easier to pass and relieving constipation without straining the client. Monitoring bowel sounds (Choice A) may be relevant for other gastrointestinal issues but is not specifically indicated for constipation. Increasing activity (Choice B) can be helpful in some cases, but it is not the first-line intervention for constipation. Encouraging bed rest (Choice D) can worsen constipation by reducing mobility and promoting inactivity.

4. A client has undergone a myelogram, and a nurse is providing post-procedure care. Which action should be included in the nursing care plan?

• A. Encourage ambulation after the procedure
• B. Maintain the prone position for 12 hours
• C. Evaluate the client's distal pulses on the affected side
• D. Encourage oral fluid intake

Correct answer: C

Rationale: The correct action to include in the nursing care plan for a client post-myelogram is to evaluate the client's distal pulses on the affected side. This is crucial to assess circulation and detect any potential complications such as impaired blood flow or vascular issues. Encouraging ambulation after the procedure (Choice A) is not typically recommended immediately post-myelogram, as the client may need to rest. Maintaining the prone position for 12 hours (Choice B) is an outdated practice and is no longer part of standard care post-myelogram. Encouraging oral fluid intake (Choice D) is generally beneficial for hydration but is not a specific priority related to post-myelogram care.

5. A client with peptic ulcer disease is being taught measures to prevent exacerbation of the condition. Which of the following instructions should the nurse include?

• A. Avoid consuming dairy products
• B. Limit alcohol consumption
• C. Use antacids frequently
• D. Drink coffee to improve digestion

Correct answer: B

Rationale: The correct answer is B: Limit alcohol consumption. Alcohol can irritate the stomach lining and worsen peptic ulcer disease. Avoiding dairy products is not necessary unless the client is lactose intolerant. Using antacids frequently may provide symptomatic relief but does not address the root cause of the condition. Drinking coffee can actually stimulate acid production and potentially aggravate peptic ulcers.

Similar Questions