Nursing Elites

1. The nurse is assessing a client with Addison's disease who is weak, dizzy, disoriented, and has dry oral mucous membranes, poor skin turgor, and sunken eyes. Vital signs are blood pressure 94/44, heart rate 123 beats/minute, respiration 22 breaths/minute. Which intervention should the nurse implement first?

• A. Assess extremity strength and resistance
• B. Report a sodium level of 132 mEq/L or mmol/L (SI units)
• C. Measure and record the cardiac QRS complex
• D. Check current finger stick glucose

Correct answer: D

Rationale: The client’s symptoms suggest possible adrenal crisis or hypoglycemia. Checking glucose is a priority to rule out hypoglycemia, which requires immediate intervention. The client is presenting with symptoms indicative of hypoglycemia, which can be life-threatening if not promptly addressed. Assessing extremity strength, reporting sodium levels, or measuring the cardiac QRS complex are not the most urgent actions in this scenario.

2. When assessing a client several hours after surgery, the nurse observes that the client grimaces and guards the incision while moving in bed. The client is diaphoretic, has a radial pulse rate of 110 beats/min, and a respiratory rate of 35 breaths/min. What assessment should the nurse perform first?

• A. Apical heart rate
• B. IV site and fluids
• C. Pain scale
• D. Temperature

Correct answer: C

Rationale: The client’s grimacing and guarding suggest pain; assessing the pain scale is crucial for addressing the discomfort. Pain management is a priority to ensure the client's well-being and comfort. Checking the apical heart rate, IV site and fluids, or temperature can be important but addressing the client's pain takes precedence in this scenario. The elevated pulse rate and respiratory rate could be indicative of pain, making the pain scale assessment essential to guide appropriate interventions.

3. In conducting the admission assessment for a client experiencing complications of long-term Parkinson’s disease, which question by the nurse provides the best information about disease progression?

• A. Have you experienced any stiffness in your neck or shoulder?
• B. Do you notice any jerky-type movements of your arms?
• C. Have you ever been frozen to a spot and unable to move?
• D. Do you have any problems with your hands shaking?

Correct answer: C

Rationale: The correct answer is C. Asking about being 'frozen to a spot and unable to move' is the most indicative of disease progression in Parkinson’s disease. Freezing episodes are a common symptom in advanced stages, indicating a more severe progression of the disease. Choices A, B, and D focus on common symptoms of Parkinson’s disease but do not specifically address the aspect of disease progression related to freezing episodes.

4. To evaluate the client's therapeutic response to lactulose for signs of hepatic encephalopathy, which assessment should the nurse obtain?

• A. Level of consciousness
• B. Percussion of abdomen
• C. Serum electrolytes
• D. Blood glucose

Correct answer: A

Rationale: The correct answer is A: Level of consciousness. Monitoring the client's level of consciousness is essential in evaluating the effectiveness of lactulose in treating hepatic encephalopathy. Lactulose helps reduce blood ammonia levels by promoting the excretion of ammonia in the stool, thereby improving the client's mental status. Assessing the client's level of consciousness helps determine if the medication is effectively managing hepatic encephalopathy symptoms. Choices B, percussion of the abdomen, and D, blood glucose, are not directly related to evaluating the therapeutic response to lactulose for hepatic encephalopathy. Choice C, serum electrolytes, while important in overall patient care, is not the primary assessment to determine lactulose's effectiveness in treating hepatic encephalopathy.

5. A child with leukemia is admitted for chemotherapy, and the nursing diagnosis, 'altered nutrition, less than body requirements related to anorexia, nausea, vomiting' is identified. Which intervention should the nurse include in this child's plan of care?

• A. Allow the child to eat foods desired and tolerated
• B. Restrict foods brought from fast food restaurants
• C. Recommend eating the same foods as siblings eat at home
• D. Encourage a variety of large portions of food at every meal

Correct answer: A

Rationale: Allowing the child to choose foods can help improve intake and reduce nausea. Choice A is the correct intervention as it empowers the child to select foods they desire and can tolerate, which is crucial in ensuring adequate nutrition intake. Choice B is incorrect because restricting certain foods can further limit the child's options and may not address the underlying issues. Choice C is incorrect as it doesn't consider the specific needs and preferences of the child with altered nutrition. Choice D is incorrect as encouraging large portions of food at every meal may be overwhelming for a child experiencing anorexia, nausea, and vomiting.

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