Nursing Elites

1. When a client's postoperative pain seems to be getting worse due to grief over the recent death of their spouse, what should the nurse consider?

• A. calling the physician for an increased dosage of pain medication
• B. calling the physician for a sedative
• C. referring the client for a psychiatric consult
• D. developing interventions for grief and loss

Correct answer: D

Rationale: The correct answer is developing interventions for grief and loss. In this scenario, the client's pain is not solely sensory but also affective due to grieving over the death of their spouse. It is essential to address the emotional component of pain by providing support and interventions for grief and loss. Referring the client for a psychiatric consult may not be necessary as grieving is a normal response to such a significant loss. Calling the physician for an increased dosage of pain medication or a sedative solely focuses on the sensory aspect of pain and does not address the underlying emotional distress.

2. A young boy is recently diagnosed with a seizure disorder. Which of the following statements by the boy's mother indicates a need for further teaching by the nurse?

• A. "I should make sure he gets plenty of rest."?
• B. "I should get him a medical alert bracelet."?
• C. "I should lay him on his back during a seizure."?
• D. "I should loosen his clothing during a seizure."?

Correct answer: C

Rationale: The correct answer is '"I should lay him on his back during a seizure."?' When a client is having a seizure, it is crucial to turn them onto their side to prevent aspiration of secretions. Placing them on their back can lead to potential airway compromise. Choices A, B, and D are correct statements that indicate a good understanding of caring for a child with a seizure disorder: ensuring rest, getting a medical alert bracelet for identification, and loosening clothing to facilitate breathing during a seizure.

3. To assess a client's ankle ROM, which ROM exercises should the nurse have them perform?

• A. flexion, extension, hyperextension
• B. flexion, extension, abduction, adduction
• C. external rotation, internal rotation
• D. extension, flexion, inversion, eversion

Correct answer: D

Rationale: The correct answer is extension, flexion, inversion, and eversion. These exercises help assess the full range of motion of the ankles. Flexion and extension evaluate the bending and straightening movements of the ankle joint, respectively. Inversion and eversion assess the inward and outward movements of the foot at the ankle joint. Hyperextension, abduction, and adduction are not specific movements of the ankle joint, making choices A and B incorrect. External and internal rotation are movements more related to joints like the hip or shoulder, not the ankle, making choice C incorrect.

4. When evaluating the lab work of a client in hepatic coma, which of the following lab tests is most important?

• A. blood urea nitrogen
• B. serum calcium
• C. serum ammonia
• D. serum creatinine

Correct answer: C

Rationale: When a client is in hepatic coma due to liver failure, the liver cannot metabolize amino acids completely, leading to elevated ammonia levels. Increased ammonia can cause brain-tissue irritation, worsening the coma. Therefore, monitoring serum ammonia levels is crucial in assessing the severity of hepatic coma. Choices A, B, and D are less relevant in the context of hepatic coma. Blood urea nitrogen primarily assesses kidney function, serum calcium levels are not directly related to hepatic coma, and serum creatinine is more indicative of kidney function rather than liver function in this scenario.

5. Which of the following ethnic groups is at highest risk in the United States for pesticide-related injuries?

• A. Native American
• B. Asian-Pacific
• C. Norwegian
• D. Hispanic

Correct answer: D

Rationale: Hispanic people are at the highest risk in the United States for pesticide-related injuries due to their significant representation among migrant workers in agricultural settings. Working in such environments exposes them to pesticides more frequently, thus elevating their risk compared to other ethnic groups. In contrast, Native American, Asian-Pacific, and Norwegian populations are not as commonly engaged in agricultural work involving pesticide exposure, which makes them less susceptible to pesticide-related injuries. Therefore, the correct answer is Hispanic.

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