Nursing Elites

1. What disorder closely matches Suzy's symptoms?

• A. Antisocial personality disorder
• B. Borderline personality disorder
• C. Schizoid personality disorder
• D. Dissociative Identity Disorder

Correct answer: B

Rationale: Suzy's symptoms are characteristic of Borderline Personality Disorder (BPD). BPD includes instability in relationships, self-image, and emotions, as well as impulsivity and self-harm. Choice A, Antisocial personality disorder, is characterized by a disregard for others' rights and lack of empathy, which does not align with Suzy's symptoms. Schizoid personality disorder, choice C, is characterized by a lack of interest in social relationships, which is not a prominent feature in Suzy's case. Dissociative Identity Disorder, choice D, involves the presence of two or more distinct identities or personality states, which is not reflected in Suzy's symptoms.

2. Which assessment finding would most likely indicate a complication of enteral tube feeding?

• A. Abdominal distension
• B. Weight gain
• C. Decreased bowel sounds
• D. Diarrhea

Correct answer: A

Rationale: Abdominal distension in a patient receiving enteral tube feeding may indicate a complication such as intolerance to feeding, delayed gastric emptying, or obstruction. Abdominal distension is a common sign of gastrointestinal issues related to enteral tube feeding. Weight gain is typically an expected outcome if the patient is receiving adequate nutrition. Decreased bowel sounds may indicate decreased motility but are not specific to enteral tube feeding complications. Diarrhea can occur due to various reasons, including infections, medications, or dietary changes, but it is not the most likely indication of a complication in enteral tube feeding.

3. When caring for a patient with a chest tube, which nursing action is most important?

• A. Clamping the chest tube every 2 hours to prevent air leaks
• B. Keeping the drainage system below chest level
• C. Emptying the drainage system every hour to prevent backflow
• D. Removing the chest tube when drainage decreases significantly

Correct answer: B

Rationale: The most crucial nursing action when caring for a patient with a chest tube is to keep the drainage system below chest level (choice B). This position helps ensure proper drainage and prevents backflow of fluid or air into the pleural space, promoting optimal functioning of the chest tube. Clamping the chest tube every 2 hours (choice A) is incorrect as it can obstruct the drainage system and lead to complications. Emptying the drainage system every hour (choice C) is unnecessary unless there are specific clinical indications. Removing the chest tube when drainage decreases significantly (choice D) is also incorrect as the decision should be based on overall clinical assessment rather than drainage amount alone.

4. An adult client is undergoing weekly external radiation treatments for breast cancer. Upon arrival at the outpatient clinic for a scheduled treatment, the client reports increasing fatigue to the PN who is taking the client's vital signs. What action should the PN implement?

• A. Notify the healthcare provider or charge nurse immediately
• B. Offer to reschedule the treatment for the following week
• C. Plan to monitor the client's vital signs every 30 minutes
• D. Reinforce the need for extra rest periods and plenty of sleep

Correct answer: D

Rationale: When a client undergoing radiation therapy reports increasing fatigue, it is essential to address this common side effect. Educating the client on the importance of rest and sleep can help manage fatigue and promote recovery. Contacting the healthcare provider or charge nurse immediately may not be necessary unless fatigue is severe and other symptoms are present. Rescheduling the treatment or monitoring vital signs more frequently is not the priority in this situation.

5. During a routine prenatal visit at the antepartal clinic, a multipara at 35-weeks gestation presents with 2+ edema of the ankles and feet. Which additional information should the PN report to the RN?

• A. Due date
• B. Blood pressure
• C. Gravida and parity
• D. Fundal height

Correct answer: B

Rationale: Blood pressure is the most critical information to report to the RN in this scenario. The presence of edema, along with high blood pressure, can be indicative of preeclampsia, a severe condition in pregnancy. Monitoring blood pressure is essential for assessing the patient's condition and taking appropriate actions if necessary. Choices A, C, and D are not as urgent in this situation. The due date, gravida, and parity are important for overall assessment but do not address the immediate concern of potential preeclampsia. Fundal height is used to assess fetal growth and position but is not the priority when edema and high blood pressure are present.

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