Nursing Elites

1. The nurse assesses distended neck veins in a client sitting in a chair to eat. What intervention is the nurse's priority?

• A. Document the observation in the chart.
• B. Measure urine specific gravity and volume.
• C. Assess the pulse and blood pressure.
• D. Assess the client's deep tendon reflexes.

Correct answer: C

Rationale: The correct answer is to assess the pulse and blood pressure. Distended neck veins can indicate fluid volume overload or heart failure, which can lead to hemodynamic instability. Assessing the pulse and blood pressure will provide immediate information on the client's cardiovascular status. Documenting the observation in the chart (choice A) is important but not the priority when immediate assessment is needed. Measuring urine specific gravity and volume (choice B) is important for assessing renal function but is not the priority in this situation. Assessing the client's deep tendon reflexes (choice D) is not relevant to addressing distended neck veins in a client sitting to eat.

2. What intervention is most important to teach the client about identifying the onset of dehydration?

• A. Measuring abdominal girth
• B. Converting ounces to milliliters
• C. Obtaining and charting daily weight
• D. Selecting food items with high water content

Correct answer: C

Rationale: The correct answer is C: Obtaining and charting daily weight. Monitoring daily weight is crucial in identifying the onset of dehydration as weight loss can be an early sign. Measuring abdominal girth (choice A) is not the most reliable method for detecting dehydration. Converting ounces to milliliters (choice B) and selecting food items with high water content (choice D) may be important for overall hydration but are not the most critical interventions for identifying the onset of dehydration.

3. A female client with deteriorating neurologic function states, "I am worried I will not be able to care for my young children."? How does the nurse respond?

• A. "Caring for your children is a priority. You may not want to ask for help, but you have to."?
• B. "Our community has resources that may help you with some household tasks so you have energy to care for your children."?
• C. "You seem distressed. Would you like to talk to a psychologist about adjusting to your changing status?"?
• D. "Give me more information about what worries you, so we can see if we can do something to make adjustments."?

Correct answer: D

Rationale: When a client expresses worry about not being able to care for her children due to deteriorating neurologic function, the most appropriate response from the nurse is to gather more information from the client. This open-ended approach allows the nurse to better understand the client's specific concerns and needs, leading to tailored interventions and support. Choice A is dismissive and may make the client feel guilty for needing help. Choice B focuses on external resources without addressing the client's worries directly. Choice C suggests a psychological referral without exploring the client's concerns further. Therefore, the correct response is to gather more information to provide personalized support.

4. How does the nurse interpret the client's actions of combing her hair only on the right side of her head and washing only the right side of her face after a stroke?

• A. Poor left-sided motor control
• B. Paralysis or contractures on the right side
• C. Limited visual perception of the left fields
• D. Unawareness of the existence of her left side

Correct answer: D

Rationale: The client's selective grooming and washing habits indicate a condition known as 'unawareness of the existence of her left side,' also called hemispatial neglect. This condition is characterized by a lack of awareness or attention to one side of the body or space, typically the left side in stroke patients. Choices A, B, and C are incorrect because the client's actions are not due to poor motor control, paralysis, contractures, or limited visual perception. Instead, they are indicative of a specific cognitive deficit related to neglecting one side of the body.

5. A client is receiving an IV infusion of an antibiotic. The client calls the nurse feeling uneasy due to congestion. Which action by the nurse is most appropriate?

• A. Elevate the head of the client's bed to 45 degrees
• B. Have another nurse call the Rapid Response Team
• C. Prepare to administer diphenhydramine (Benadryl)
• D. Slow the rate of the IV infusion

Correct answer: B

Rationale: In this situation, the client's symptoms of congestion and feeling uneasy may indicate an anaphylactic reaction, which can be life-threatening. The most appropriate action is to call the Rapid Response Team to provide immediate assistance and interventions. Elevating the head of the bed, administering diphenhydramine, or slowing the IV infusion rate are not the priority actions in the case of a potential severe allergic reaction. These interventions may delay necessary emergency care and potentially worsen the client's condition.

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