Nursing Elites

1. What is the most important information for a nurse to obtain when an older female client expresses not deserving to eat due to lack of money?

• A. Client's thoughts about wanting to hurt herself
• B. Medication history for antipsychotic agents
• C. Availability of family members to provide meals
• D. Community resources to provide financial aid

Correct answer: A

Rationale: The correct answer is A: Client's thoughts about wanting to hurt herself. When a client expresses not deserving to eat due to lack of money, it raises concerns about her mental and emotional well-being. Assessing for suicidal ideation is crucial in this situation to ensure the client's immediate safety. Options B, C, and D are not the most critical information to obtain in this scenario. While medication history, family support, and community resources are important aspects of care, in this context, the client's mental health and risk of self-harm take precedence.

2. The nurse is preparing a presentation on sexually transmitted infections (STIs) for a group of high school students. Which strategy is most effective for this age group?

• A. providing detailed statistical data on STI rates
• B. distributing brochures about STI prevention
• C. showing a documentary on the impact of STIs
• D. facilitating a discussion on safe sex practices

Correct answer: D

Rationale: Facilitating a discussion on safe sex practices is the most effective strategy for high school students when educating about sexually transmitted infections (STIs). This approach encourages active participation, allows students to ask questions, share experiences, and engage with the topic in a meaningful way. Providing detailed statistical data may overwhelm the students and not resonate with them effectively. Distributing brochures can be informative but might not promote the same level of interaction and understanding as a discussion. Showing a documentary is a passive method that may not engage the students actively or address their specific questions and concerns.

3. A client with a head injury is admitted to the hospital. Which finding indicates a need for immediate intervention?

• A. Glasgow Coma Scale (GCS) score of 15.
• B. Pupils are equal and reactive to light.
• C. Client is drowsy but arousable.
• D. Client does not remember the events leading to the injury.

Correct answer: C

Rationale: In a client with a head injury, being drowsy but still arousable can be a sign of increased intracranial pressure, which necessitates immediate intervention. This presentation may indicate a deterioration in neurological status, requiring prompt assessment and management to prevent further complications. Choices A, B, and D are not indicative of an immediate need for intervention in this scenario. A Glasgow Coma Scale (GCS) score of 15 indicates the highest level of consciousness; pupils being equal and reactive to light suggest intact cranial nerve function, and memory loss about the injury event is common in head injuries and does not necessarily warrant immediate intervention.

4. A client with a history of heart failure is admitted with pulmonary edema. Which finding requires immediate intervention?

• A. Peripheral edema.
• B. Oxygen saturation of 88%.
• C. Jugular vein distention.
• D. Productive cough with pink, frothy sputum.

Correct answer: D

Rationale: A productive cough with pink, frothy sputum is a classic sign of pulmonary edema, indicating fluid in the lungs. This finding requires immediate intervention to prevent respiratory compromise and worsening of the condition. Peripheral edema (Choice A) is a manifestation of heart failure but is not as urgent as addressing pulmonary edema. Oxygen saturation of 88% (Choice B) is low and requires attention, but the pink, frothy sputum signifies acute respiratory distress. Jugular vein distention (Choice C) can be seen in heart failure, but the immediate concern in this scenario is addressing the pulmonary edema to ensure adequate gas exchange and oxygenation.

5. The healthcare provider is assessing a client who has a new arteriovenous fistula in the left arm for hemodialysis. Which finding requires immediate intervention?

• A. A thrill is palpable on the fistula.
• B. The client's arm is warm and red.
• C. The fistula has a bruit on auscultation.
• D. There is no bruit on auscultation.

Correct answer: B

Rationale: The correct answer is B. Warmth and redness in the client's arm suggest infection or thrombosis of the arteriovenous fistula, which requires immediate intervention to prevent complications. A thrill (A) is a normal finding in a functional arteriovenous fistula, indicating good blood flow. A bruit (C) is also a normal finding on auscultation of a functioning arteriovenous fistula, indicating proper blood flow. The absence of a bruit (D) may indicate a non-functioning fistula, which would need further evaluation but does not require immediate intervention as warmth and redness do.

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