Nursing Elites

1. Mrs. Jordan is an elderly client diagnosed with Alzheimer’s disease. She becomes agitated and combative when a nurse approaches to help with morning care. The most appropriate nursing intervention in this situation would be to:

• A. tell the client firmly that it is time to get dressed.
• B. obtain assistance to restrain the client for safety.
• C. remain calm and talk quietly to the client.
• D. call the doctor and request an order for sedation.

Correct answer: C

Rationale: When dealing with an elderly client with Alzheimer’s disease who is agitated and combative, the most appropriate nursing intervention is to remain calm and talk quietly to the client. This approach can help soothe the client and prevent escalating the situation. Choice A is incorrect as being firm may further agitate the client. Choice B is inappropriate as restraining should only be used as a last resort for safety reasons and after other de-escalation techniques have been attempted. Choice D is not the best initial intervention and should only be considered after other non-pharmacological interventions have failed.

2. A 10-year-old male is stung by a bee while playing in the yard. He begins itching and develops pain, swelling, redness, and respiratory difficulties. He is suffering from:

• A. Immunodeficiency
• B. Autoimmunity
• C. Anaphylaxis
• D. Tissue-specific hypersensitivity

Correct answer: C

Rationale: The correct answer is C: Anaphylaxis. Anaphylaxis is a severe, immediate allergic reaction mediated by IgE. In this scenario, the symptoms of itching, pain, swelling, redness, and respiratory difficulties following a bee sting are indicative of anaphylaxis. Choice A, Immunodeficiency, refers to a weakened immune system's inability to protect the body from infections and diseases, which is not the case here. Choice B, Autoimmunity, involves the immune system attacking healthy cells and tissues by mistake, which is not the mechanism at play in anaphylaxis. Choice D, Tissue-specific hypersensitivity, does not accurately describe the immediate, systemic reaction seen in anaphylaxis.

3. A patient has been prescribed clomiphene citrate (Clomid) for infertility. What should the nurse include in the teaching plan about the use of this medication?

• A. Clomiphene is taken daily for 5 days at the beginning of the menstrual cycle.
• B. Clomiphene is taken once daily throughout the menstrual cycle.
• C. Clomiphene is taken twice daily for 5 days at the end of the menstrual cycle.
• D. Clomiphene is taken three times daily for 10 days at the beginning of the menstrual cycle.

Correct answer: A

Rationale: Corrected Rationale: Clomiphene is typically taken daily for 5 days at the beginning of the menstrual cycle to stimulate ovulation. Choice A is the correct answer because it aligns with the standard dosing regimen for clomiphene citrate. Choices B, C, and D provide incorrect information about the dosing schedule for clomiphene, which can lead to ineffective treatment and potential side effects. Choice B suggests continuous daily intake, which is not the standard practice for clomiphene. Choice C and D mention different dosing frequencies and timings, which are not in line with the typical protocol for using clomiphene for infertility.

4. When planning care for a cardiac patient, the nurse knows that in response to an increased workload, cardiac myocardial cells will:

• A. Increase in size
• B. Decrease in length
• C. Increase in excitability
• D. Increase in number

Correct answer: A

Rationale: The correct answer is A: Increase in size. Cardiac hypertrophy occurs when myocardial cells increase in size to compensate for an increased workload. This adaptation allows the heart to pump more effectively. Choice B, Decrease in length, is incorrect as cardiac cells do not decrease in length in response to increased workload. Choice C, Increase in excitability, is incorrect as increased workload does not lead to an increase in excitability of cardiac cells. Choice D, Increase in number, is incorrect as cardiac cells do not increase in number but rather increase in size to handle the increased workload.

5. A client with a history of chronic alcoholism presents to the emergency department with a complaint of double vision. Which cranial nerve is most likely involved?

• A. Cranial nerve I (Olfactory)
• B. Cranial nerve III (Oculomotor)
• C. Cranial nerve VI (Abducens)
• D. Cranial nerve VII (Facial)

Correct answer: C

Rationale: The correct answer is Cranial nerve VI (Abducens). Chronic alcoholism can lead to damage to the abducens nerve, which controls the lateral movement of the eye. This damage can result in symptoms like double vision. Cranial nerve I (Olfactory) is responsible for the sense of smell and is not related to eye movement. Cranial nerve III (Oculomotor) controls most of the eye movements but is less likely to be affected in chronic alcoholism than the abducens nerve. Cranial nerve VII (Facial) is responsible for facial movements and is not associated with double vision.

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