Nursing Elites

1. The client had a thyroidectomy 24 hours ago and reports experiencing numbness and tingling of the face. Which intervention should the nurse implement?

• A. Open and prepare the tracheostomy kit.
• B. Inspect the neck for an increase in swelling.
• C. Monitor for the presence of Chvostek's sign.
• D. Assess lung sounds for laryngeal stridor.

Correct answer: C

Rationale: The correct answer is C: Monitor for the presence of Chvostek's sign. Chvostek's sign is a clinical indicator of hypocalcemia, a common complication after thyroidectomy. Numbness and tingling around the face are associated with hypocalcemia due to potential damage to the parathyroid glands during surgery, leading to decreased calcium levels. Inspecting the neck for swelling (choice B) is important but does not directly address the presenting symptoms. Opening and preparing the tracheostomy kit (choice A) is not necessary based on the client's current symptoms. Assessing lung sounds for laryngeal stridor (choice D) is not directly related to the client's reported numbness and tingling of the face.

2. A client with a history of type 1 diabetes Mellitus (DM) and asthma is readmitted to the unit for the third time in two months with a current fasting blood sugar (FBS) of 325mg/dl (18mmol/L SI). The client describes to the nurse not understanding why the blood glucose level continues to be out of control. Which interventions should the nurse implement?

• A. Have the client describe a typical day at work, home, and social activities
• B. Determine if the client is using a new insulin needle for each administration
• C. Evaluate the client's asthma medications that can elevate blood glucose
• D. Have the client demonstrate the technique used to monitor blood glucose levels

Correct answer: A

Rationale: The correct answer is to have the client describe a typical day at work, home, and social activities. By understanding the client's daily routine, the nurse can gain valuable insights into lifestyle factors that may be impacting blood glucose control. This information is essential for identifying potential triggers or patterns contributing to the elevated blood sugar levels. Option B, determining if the client is using a new insulin needle for each administration, focuses more on the technical aspect of insulin delivery and is not directly related to daily activities affecting blood glucose levels. Option C, evaluating the client's asthma medications that can elevate blood glucose, could be relevant but is not as directly linked to the client's lifestyle choices as option A. Option D, having the client demonstrate the technique for monitoring blood glucose levels, is important for assessing their skills but does not provide information on daily activities that may be influencing blood sugar levels.

3. In the change-of-shift report, the nurse is told that a client has a Stage 2 pressure ulcer. Which ulcer appearance is most likely to be observed?

• A. Shallow open ulcer with a red-pink wound bed.
• B. A deep pocket of infection and necrotic tissues.
• C. An area of erythema that is painful to touch.
• D. Visible subcutaneous tissue with sloughing.

Correct answer: A

Rationale: A Stage 2 pressure ulcer typically presents as a shallow open ulcer with a red-pink wound bed. This appearance is characteristic of a Stage 2 pressure ulcer where there is partial thickness skin loss involving the epidermis and possibly the dermis. Choice B, a deep pocket of infection and necrotic tissues, is more indicative of a Stage 3 or Stage 4 pressure ulcer where the ulcer extends into deeper tissue layers. Choice C, an area of erythema that is painful to touch, is more commonly seen in early-stage pressure ulcers such as Stage 1. Choice D, visible subcutaneous tissue with sloughing, is characteristic of a more severe stage of pressure ulcer beyond Stage 2.

4. After educating a client with stress incontinence, the nurse assesses the client’s understanding. Which statement made by the client indicates a need for additional teaching?

• A. I will limit my total intake of fluids.
• B. I must avoid drinking alcoholic beverages.
• C. I must avoid drinking caffeinated beverages.
• D. I shall try to lose about 10% of my body weight.

Correct answer: A

Rationale: The correct answer is A. Limiting fluids can worsen stress incontinence by concentrating urine and irritating tissues, leading to increased incontinence. Adequate hydration is important to maintain bladder health and function. Choices B and C are correct as avoiding alcoholic and caffeinated beverages can help reduce bladder irritation. Choice D is also correct as losing about 10% of body weight can help reduce intra-abdominal pressure, which is beneficial in managing stress incontinence.

5. The healthcare provider is assessing an older Caucasian male who has a history of peripheral vascular disease. The healthcare provider observes that the man's left great toe is black. The discoloration is probably a result of:

• A. Atrophy.
• B. Contraction.
• C. Gangrene.
• D. Rubor.

Correct answer: C

Rationale: Gangrene refers to dead, blackened tissue, often a result of chronic ischemia in clients with peripheral vascular disease. Atrophy (Choice A) is the wasting away or decrease in size of tissue or organ. Contraction (Choice B) refers to the shortening or tightening of a muscle or other body part. Rubor (Choice D) is a red discoloration of the skin, often associated with inflammation or poor circulation, but not typically presenting as blackening like gangrene.

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