Nursing Elites

1. A client is scheduled for a lumbar puncture. The nurse should assist the client into which of the following positions?

• A. Supine with head elevated
• B. Lateral recumbent
• C. Prone with arms at sides
• D. Sitting with back rounded

Correct answer: B

Rationale: The correct position for a lumbar puncture is the lateral recumbent position. This position allows the spine to curve naturally, widening the spaces between the vertebrae, making it easier and safer to perform the procedure. Supine with head elevated (Choice A) would not provide the proper positioning for a lumbar puncture as it does not allow for proper access to the lumbar area. Prone with arms at sides (Choice C) would not be suitable as it would not facilitate the procedure. Sitting with back rounded (Choice D) is also incorrect as it does not allow for the proper alignment of the spine needed for a lumbar puncture.

2. A nurse is observing an assistive personnel (AP) caring for a client. For which of the following actions by the AP should the nurse intervene?

• A. Providing care in the hallway
• B. Reporting client information in the hallway
• C. Helping another client use the restroom
• D. Feeding the client too quickly

Correct answer: B

Rationale: The correct answer is B because reporting client information in the hallway violates privacy regulations, compromising patient confidentiality. Providing care in the hallway (choice A) may not be ideal but is not a direct violation. Helping another client use the restroom (choice C) shows the AP's willingness to assist but is not a concern unless it compromises the current client's safety. Feeding the client too quickly (choice D) is a potential concern for aspiration but may not require immediate intervention as addressing hydration and swallowing strategies can help prevent complications.

3. A healthcare professional is collecting data from a client who is experiencing post-traumatic stress disorder (PTSD). Which of the following manifestations should the healthcare professional expect?

• A. Hyperactivity
• B. Hypervigilance
• C. Restlessness
• D. Avoidance of social situations

Correct answer: B

Rationale: Hypervigilance is a common manifestation of PTSD characterized by heightened alertness and fear of danger. This heightened state of awareness can lead to irritability, difficulty concentrating, and sleep disturbances. Choices A, C, and D are incorrect. Hyperactivity is not typically associated with PTSD; restlessness may be present but is not the primary manifestation, and avoidance of social situations is more commonly seen in conditions like social anxiety disorder rather than PTSD.

4. What are the complications of untreated hyperglycemia?

• A. Diabetic ketoacidosis and dehydration
• B. Hypoglycemia and hypertension
• C. Infection and liver failure
• D. Pulmonary edema and electrolyte imbalance

Correct answer: A

Rationale: The correct answer is A: Diabetic ketoacidosis and dehydration. Untreated hyperglycemia can lead to diabetic ketoacidosis, a serious complication characterized by high blood sugar, the presence of ketones in the urine, and acidosis. Dehydration is also a common complication of untreated hyperglycemia. Choices B, C, and D are incorrect because hypoglycemia and hypertension are not typical complications of untreated hyperglycemia. Infection and liver failure, as well as pulmonary edema and electrolyte imbalance, are also not direct complications of untreated hyperglycemia.

5. A nurse is collecting data from a client who is experiencing a situational crisis following the loss of a job. The client states, 'I don't think I can go through this again.' Which of the following actions is the nurse's priority?

• A. Determine if the client is experiencing psychotic thinking
• B. Determine the client's support system
• C. Ask how the client copes with stress
• D. Assess the client's vital signs

Correct answer: A

Rationale: The priority is to determine if the client is experiencing psychotic thinking or suicidal ideation. In this situation, the nurse needs to assess if the client is having distorted thoughts or losing touch with reality, which could pose an immediate risk to the client's safety. While determining the client's support system, asking how the client copes with stress, and assessing vital signs are important aspects of care, they are not the priority when there is a concern about potential psychotic thinking or suicidal ideation.

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