Nursing Elites

1. During the care of a client with Legionnaire's disease, which finding would require the nurse's immediate attention?

• A. Pleuritic pain on inspiration
• B. Dry mucus membranes in the mouth
• C. A decrease in respiratory rate from 34 to 24
• D. Decrease in chest wall expansion

Correct answer: D

Rationale: A decrease in chest wall expansion suggests that the client may be experiencing a serious complication, such as worsening pneumonia or respiratory failure, requiring immediate medical attention. This finding indicates a potential decrease in lung function, which could lead to respiratory distress. Pleuritic pain on inspiration may be related to the disease process but does not indicate an immediate need for intervention. Dry mucus membranes in the mouth may require attention but are not as critical as a decrease in chest wall expansion. A decrease in respiratory rate could be concerning but is not as urgent as a decrease in chest wall expansion, which directly impacts respiratory function.

2. The nurse is caring for a client admitted to the hospital with right lower lobe (RLL) pneumonia. On assessment, the nurse notes crackles over the RLL. The client has significant pleuritic pain and is unable to take in a deep breath in order to cough effectively.

• A. Impaired gas exchange related to acute infection and sputum production
• B. Ineffective airway clearance related to sputum production and ineffective cough
• C. Ineffective breathing pattern related to acute infection
• D. Anxiety related to hospitalization and role conflict

Correct answer: B

Rationale: The client's inability to effectively clear the airway due to pain and sputum production hinders the cough mechanism, making 'Ineffective airway clearance' the most appropriate nursing diagnosis. Although impaired gas exchange may occur due to the pneumonia, the immediate issue is the inability to clear the airway. 'Ineffective breathing pattern' does not address the specific issue of airway clearance. 'Anxiety' is not the priority when the focus should be on the physical complications of pneumonia.

3. In addition to disturbances in mental awareness and orientation, a client with cognitive impairment is also likely to show loss of ability in

• A. Hearing, speech, and sight
• B. Endurance, strength, and mobility
• C. Learning, creativity, and judgment
• D. Balance, flexibility, and coordination

Correct answer: C

Rationale: Individuals with cognitive impairment often experience difficulties in learning new information, creative thinking, and making sound judgments. Loss of ability in hearing, speech, and sight (Choice A) is more closely related to sensory impairments rather than cognitive impairment. Endurance, strength, and mobility (Choice B) are more associated with physical capabilities rather than cognitive functions. Balance, flexibility, and coordination (Choice D) are related to motor skills and physical coordination, not cognitive impairment.

4. The nurse is caring for a 75-year-old client in congestive heart failure. Which finding suggests that digitalis levels should be reviewed?

• A. Extreme fatigue
• B. Increased appetite
• C. Intense itching
• D. Constipation

Correct answer: A

Rationale: Extreme fatigue can be a sign of digitalis toxicity, especially in older adults, and warrants a review of the client's medication levels and potential adjustment. Increased appetite, intense itching, and constipation are not typically associated with digitalis toxicity and do not directly indicate a need for a review of digitalis levels.

5. A client with bipolar disorder is receiving lithium (Lithobid). The nurse should monitor the client for which of the following side effects?

• A. Hypernatremia
• B. Hyponatremia
• C. Hyperglycemia
• D. Hypercalcemia

Correct answer: B

Rationale: The correct answer is B: Hyponatremia. Lithium can lead to hyponatremia by affecting sodium balance in the body. Hypernatremia (Choice A) is unlikely with lithium use. Hyperglycemia (Choice C) and hypercalcemia (Choice D) are not typically associated with lithium therapy for bipolar disorder.

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