Nursing Elites

1. In a disaster situation, the nurse assessing a diabetic client on insulin assesses for all of the following except:

• A. diabetic signs and symptoms.
• B. nutritional status.
• C. bleeding problems.
• D. availability of insulin.

Correct answer: C

Rationale: In a disaster situation, when assessing a diabetic client on insulin, the nurse should assess for diabetic signs and symptoms to monitor the client's condition, nutritional status to ensure proper dietary management, and availability of insulin to maintain the client's medication regimen. Bleeding problems are not directly related to diabetes or insulin use, making it the exception in this assessment scenario. Therefore, bleeding problems would not be a typical focus of assessment in this context.

2. Which of the following symptoms is not indicative of autonomic dysreflexia in the client with a spinal cord injury?

• A. sudden onset of headache
• B. flushed face
• C. hypotension
• D. nasal congestion

Correct answer: C

Rationale: Autonomic dysreflexia is characterized by a sudden onset of symptoms due to an overactive autonomic nervous system. Hypotension is not indicative of autonomic dysreflexia; instead, hypertension is a hallmark sign. Therefore, hypotension is the correct answer. Flushed face, sudden onset of headache, and nasal congestion are classic symptoms of autonomic dysreflexia caused by a noxious stimulus below the level of the spinal cord injury. These symptoms result from the body's attempt to regulate blood pressure when the normal feedback loop is interrupted.

3. Where do the vast majority of deaths resulting from unintentional poisoning occur?

• A. Infants
• B. Toddlers
• C. Teens
• D. Adults

Correct answer: B

Rationale: The correct answer is 'Toddlers.' Toddlers are at the highest risk of unintentional poisoning due to their natural curiosity, explorative behavior, and lack of awareness of potential dangers. Infants are typically closely monitored, teens are more aware of risks, and adults generally have better judgment and understanding of hazardous substances, making them less susceptible to unintentional poisoning. Therefore, toddlers, being inquisitive and unaware of risks, are the most vulnerable group in terms of unintentional poisoning incidents.

4. When preparing a client for a neck x-ray, what is the most appropriate action for the nurse to take if the client expresses concern about removing a religious medal worn around the neck?

• A. Telling the client that the medal and chain will be kept at the nurse's station for safekeeping while the client is undergoing the x-ray
• B. Asking the client to remove the medal until the x-ray has been completed
• C. Assisting the client in pinning the medal and chain to the waistband of the client's pajama bottoms
• D. Asking the client to place the medal in the top drawer of the bedside stand just before leaving for the radiology department

Correct answer: C

Rationale: When a client undergoing a neck x-ray expresses concern about removing a religious medal worn around the neck, the nurse should assist the client in pinning the medal and chain to the hospital gown or in another area where it will not appear on the x-ray image. This action allows the client to keep the medal close without interfering with the x-ray procedure. It is important to ensure that the radiology department staff is informed about this arrangement. Asking the client to remove the medal, keeping it at the nurse's station, or placing it in the bedside stand is not appropriate. These actions may lead to the loss of the medal and chain and do not address the client's concerns about the religious significance of the item.

5. Which of the following is not one of the four categories related to client care plans?

• A. privacy
• B. evaluation
• C. diagnosis
• D. outcome

Correct answer: A

Rationale: The four categories related to client care plans are diagnosis, intervention, outcome, and evaluation. Privacy is not typically considered a distinct category in client care plans, as it is more of a fundamental aspect that underlies all care provided to clients. Choices B, C, and D are directly related to the components of client care plans, making them incorrect answers in this context.

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