Nursing Elites

1. Following a lumbar puncture, a client complains of worsening headache when sitting up. What complication is the client likely experiencing?

• A. A migraine headache
• B. An infection from the puncture site
• C. Low blood sugar
• D. Spinal fluid leakage (post-lumbar puncture headache)

Correct answer: D

Rationale: The client is likely experiencing spinal fluid leakage (post-lumbar puncture headache), a common complication of a lumbar puncture. This leakage results in a reduction of cerebrospinal fluid volume around the brain and spinal cord, leading to a headache that worsens when in an upright position due to reduced buoyancy. A migraine headache (Choice A) is not typically associated with a lumbar puncture. Infection from the puncture site (Choice B) would present with localized signs of inflammation, such as redness, swelling, and warmth, rather than worsening headache. Low blood sugar (Choice C) is not a common complication of lumbar puncture and would not typically manifest as a worsening headache when sitting up.

2. A client with schizophrenia is experiencing auditory hallucinations. What is the nurse's best response?

• A. Encourage the client to ignore the voices and stay focused on reality.
• B. Acknowledge the client's feelings and ask what the voices are saying.
• C. Redirect the conversation to help distract the client from the hallucinations.
• D. Offer reassurance that the voices cannot harm the client.

Correct answer: B

Rationale: The best response for a client with schizophrenia experiencing auditory hallucinations is to acknowledge the client's feelings and ask what the voices are saying. This approach helps build rapport with the client, demonstrates empathy, and allows the nurse to assess the content of the hallucinations. Understanding the content is crucial to determine whether the client is at risk of harm. Encouraging the client to ignore the voices (Choice A) may invalidate their experience. Redirecting the conversation (Choice C) may not address the underlying issue of the hallucinations. Offering reassurance (Choice D) without understanding the content may overlook potential risks.

3. The nurse is providing care for a client with heart failure who is prescribed furosemide. Which laboratory value should the nurse monitor closely?

• A. Calcium level
• B. Sodium level
• C. Magnesium level
• D. Potassium level

Correct answer: D

Rationale: The correct answer is D: Potassium level. Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Monitoring potassium levels is crucial to prevent complications such as cardiac arrhythmias. While calcium, sodium, and magnesium levels are important in various conditions and treatments, they are not the primary electrolyte affected by furosemide.

4. While palpating the gallbladder of a mildly obese client, what finding does the nurse expect if the gallbladder is inflamed?

• A. Severe tenderness and guarding
• B. Slight discomfort upon palpation
• C. A sensation of fullness
• D. No symptoms unless the gallbladder is extremely inflamed

Correct answer: A

Rationale: Correct. If the gallbladder is inflamed, the nurse would expect to find severe tenderness and guarding, which are typical signs of acute cholecystitis. This indicates an inflammatory process in the gallbladder. Choices B, C, and D are incorrect because slight discomfort, a sensation of fullness, or no symptoms unless extremely inflamed are not typical findings associated with gallbladder inflammation.

5. The nurse is providing discharge teaching to a client with asthma. Which statement indicates the client understands how to use a rescue inhaler?

• A. I will use my rescue inhaler every morning to prevent asthma attacks.
• B. I should use my rescue inhaler when I start to experience wheezing.
• C. I will use my rescue inhaler when my peak flow meter reading is in the green zone.
• D. I will only use my rescue inhaler before going to bed.

Correct answer: B

Rationale: The correct answer is B: 'I should use my rescue inhaler when I start to experience wheezing.' A rescue inhaler is used during the onset of asthma symptoms, such as wheezing, to quickly open the airways. It is not intended for routine daily use or prevention, which is the role of a maintenance inhaler. Option A is incorrect because a rescue inhaler is not used for prevention but for immediate relief during an asthma attack. Option C is incorrect because the peak flow meter reading is used to monitor asthma control, not to determine when to use a rescue inhaler. Option D is incorrect because using a rescue inhaler only before going to bed does not address the need for immediate relief when wheezing or experiencing asthma symptoms.

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