Nursing Elites

1. A nurse is preparing to teach a client about the management of hypoglycemia. Which sign should the nurse instruct the client to monitor for?

• A. Diaphoresis
• B. Polyuria
• C. Abdominal pain
• D. Thirst

Correct answer: A

Rationale: The correct answer is A: Diaphoresis. Diaphoresis, which refers to excessive sweating, is a classic symptom of hypoglycemia. Instructing the client to monitor for diaphoresis is crucial as it can help them recognize and address hypoglycemic events promptly. Polyuria (excessive urination), abdominal pain, and thirst are not typical signs of hypoglycemia. Polyuria is more commonly associated with conditions like diabetes mellitus, while abdominal pain and thirst are not specific indicators of low blood sugar levels.

2. A nurse is assessing a client who has a femur fracture and is in skeletal traction. Which of the following findings should the nurse report to the provider?

• A. Clear fluid drainage from the pin sites
• B. Client reporting intermittent muscle spasms
• C. Client reporting severe pain despite receiving analgesics
• D. The traction weights are hanging freely

Correct answer: C

Rationale: The correct answer is C. Severe pain that is not relieved by analgesics may indicate neurovascular compromise or other complications and requires immediate attention by the provider. Choices A, B, and D are incorrect because clear fluid drainage from the pin sites is expected in skeletal traction, intermittent muscle spasms are common in this situation, and traction weights hanging freely indicate proper traction alignment.

3. A nurse is admitted to a psychiatric unit and fails to follow her medication regimen. What does this behavior indicate?

• A. Early cognitive impairment
• B. Lack of motivation
• C. Lack of health literacy
• D. Worsening health state

Correct answer: C

Rationale: The correct answer is C, 'Lack of health literacy.' The nurse's inability to follow the medication regimen suggests she may lack health literacy, meaning she may not fully understand how to manage her own health care. Choice A, 'Early cognitive impairment,' is not supported by the information provided in the question as there is no mention of cognitive decline. Choice B, 'Lack of motivation,' is less likely as the behavior is more indicative of a knowledge deficit rather than a lack of drive. Choice D, 'Worsening health state,' is also less likely as the behavior described does not directly imply a worsening health condition but rather a misunderstanding or lack of knowledge on managing health.

4. A hospice nurse is providing teaching to a patient who has a new diagnosis of a terminal illness and her family. Which statement should the nurse include in the teaching?

• A. Hospice care will help provide rehabilitation for the patient.
• B. Hospice care focuses on extending life by any means necessary.
• C. Hospice care will help the patient transition to nursing care.
• D. Hospice care continues to help families with grief after a death occurs.

Correct answer: D

Rationale: The correct statement that the nurse should include in the teaching is option D: 'Hospice care continues to help families with grief after a death occurs.' Hospice care not only focuses on providing comfort care for terminal patients but also offers bereavement support to families after the patient's death. Choices A, B, and C are incorrect. Option A is incorrect because hospice care does not provide rehabilitation for the patient; its focus is on comfort and quality of life. Option B is incorrect because hospice care does not aim to extend life but rather to provide quality end-of-life care. Option C is incorrect because hospice care does not transition patients to nursing care; it provides care focused on comfort and symptom management in the patient's preferred setting.

5. What is the first action when a client who is admitted with schizophrenia reports hearing voices telling them to harm themselves?

• A. Administer antipsychotic medication
• B. Ask the client what the voices are saying
• C. Distract the client with another activity
• D. Call the healthcare provider

Correct answer: B

Rationale: The correct first action when a client with schizophrenia reports hearing voices telling them to harm themselves is to ask the client what the voices are saying. This is important to assess the content of the hallucinations and determine if there is any immediate danger or suicidal intent. Administering antipsychotic medication without knowing the content of the voices or the level of danger could be inappropriate and potentially harmful. Distracting the client with another activity may not address the underlying issue of the hallucinations commanding harm. Calling the healthcare provider can be done after assessing the situation and gathering information from the client.

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