Nursing Elites

1. A nurse is teaching a group of assistive personnel (AP) about caring for clients who have Alzheimer's disease. Which of the following information should the nurse include in the teaching?

• A. Explain procedures clearly and concisely to the client before initiating care
• B. Encourage a client's engagement in appropriate activities to minimize emotional outbursts
• C. Speak calmly and at a moderate volume to a client who is unable to form words or sentences
• D. Provide supervision to prevent a client from becoming injured or lost

Correct answer: D

Rationale: The correct answer is D because clients with Alzheimer's disease are at risk of wandering and becoming lost. Providing supervision helps prevent them from getting injured or lost. Choice A is incorrect because extensive details may overwhelm clients with Alzheimer's. Choice B is incorrect because limiting activities can lead to boredom and behavioral issues. Choice C is incorrect because speaking calmly and at a moderate volume helps to reduce agitation and confusion in clients with Alzheimer's.

2. What should be monitored in a patient receiving insulin who is at risk for hypoglycemia?

• A. Monitor blood glucose levels
• B. Monitor for respiratory distress
• C. Monitor for hypertension
• D. Monitor for hyperkalemia

Correct answer: A

Rationale: Corrected Question: In a patient receiving insulin who is at risk for hypoglycemia, monitoring blood glucose levels is crucial. This helps in preventing and identifying hypoglycemia promptly. Choice B, monitoring for respiratory distress, is not directly related to hypoglycemia caused by insulin. Choice C, monitoring for hypertension, is not typically associated with hypoglycemia. Choice D, monitoring for hyperkalemia, is not a common concern in patients receiving insulin who are at risk for hypoglycemia.

3. What is the priority intervention for a patient with unstable angina?

• A. Administer nitroglycerin
• B. Establish IV access
• C. Auscultate heart sounds
• D. Administer aspirin

Correct answer: A

Rationale: The correct answer is to administer nitroglycerin. Nitroglycerin is the priority intervention for a patient with unstable angina as it helps dilate blood vessels, improve blood flow to the heart, relieve chest pain, and prevent further cardiac damage. Establishing IV access (choice B) may be important but is not the priority over administering nitroglycerin in this scenario. Auscultating heart sounds (choice C) and administering aspirin (choice D) are also important aspects of managing unstable angina, but they are not the immediate priority intervention when a patient is experiencing chest pain.

4. A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine. Which of the following interventions should the nurse include in the plan?

• A. Inspect the pin site every 4 hours
• B. Monitor the client's skin under the halo vest
• C. Ensure two personnel hold the halo device when repositioning the client
• D. Apply powder to the client's skin under the vest to decrease itching

Correct answer: B

Rationale: The correct answer is to monitor the client's skin under the halo vest. This is important to assess for signs of skin issues such as excessive sweating, redness, or blistering, which can lead to skin breakdown and infection. Choice A is incorrect because while inspecting the pin site is important, it should be done more frequently than every 4 hours. Choice C is incorrect as the halo device should be supported by the client's body weight, not personnel, when repositioning. Choice D is incorrect because applying powder frequently can increase the risk of skin irritation and infection.

5. What are the manifestations of increased intracranial pressure (IICP)?

• A. Restlessness, confusion, irritability
• B. Severe nausea and vomiting
• C. Elevated blood pressure and bradycardia
• D. Decreased heart rate and altered pupil response

Correct answer: A

Rationale: The correct manifestations of increased intracranial pressure (IICP) include restlessness, confusion, and irritability. These symptoms are a result of the brain being under pressure inside the skull. Severe nausea and vomiting (Choice B) are more commonly associated with increased intracranial pressure in children. Elevated blood pressure and bradycardia (Choice C) are not typical manifestations of increased intracranial pressure; instead, hypertension and bradycardia may be seen in Cushing's reflex, which is a late sign of increased IICP. Decreased heart rate and altered pupil response (Choice D) are also not primary manifestations of increased intracranial pressure, although altered pupil response, like a non-reactive or dilated pupil, can be seen in some cases.

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