Nursing Elites

1. The nurse is caring for a client with cirrhosis of the liver and suspects that the client may be developing hepatic encephalopathy. Which assessment by the nurse suggests that the client is developing this complication?

• A. Asterixis
• B. Hypertension
• C. Kussmaul respirations
• D. Lethargy

Correct answer: A

Rationale: Asterixis, also known as flapping tremors, is a characteristic sign of hepatic encephalopathy. It is a flapping tremor of the hands when the wrists are extended, indicating neurological impairment. Hypertension and Kussmaul respirations are not directly associated with hepatic encephalopathy. Lethargy is a common symptom but not a specific sign that suggests the development of hepatic encephalopathy.

2. A client newly diagnosed with Diabetes Mellitus needs education. Which of the following statements should the nurse include in this education?

• A. "You can eat anything you want, but avoid foods with sugar."?
• B. "You need to lose weight, so your diet must be controlled."?
• C. "You need a diet and exercise program."?
• D. "You must reduce salt, fat, and sugar intake in your diet."?

Correct answer: C

Rationale: A client newly diagnosed with Diabetes Mellitus requires education on managing their condition. Choice C is the correct answer because it emphasizes the importance of a comprehensive approach involving both diet and exercise. This holistic approach is crucial in managing blood sugar levels and overall health for individuals with diabetes. Choice A is incorrect as it provides misleading information by suggesting that the client can eat anything as long as it doesn't contain sugar, which is not accurate for diabetes management. Choice B is not the best option as it focuses solely on weight loss rather than addressing the holistic needs of a diabetic individual. Choice D is incorrect as it suggests eliminating all salt, fat, and sugar, which is an extreme approach and not a realistic or balanced way to manage diabetes.

3. Why must the nurse be careful not to cut through or disrupt any tears, holes, bloodstains, or dirt present on the clothing of a client who has experienced trauma?

• A. The clothing may be potential evidence with legal implications.
• B. Such care facilitates the preservation of potential evidence.
• C. The clothing of a trauma victim can be used for further investigation.
• D. Such care maintains the integrity of the clothing for forensic analysis.

Correct answer: C

Rationale: In cases of trauma, the clothing of a client can hold crucial evidence that may have legal implications. It is essential for the nurse to avoid cutting through or disrupting any tears, holes, bloodstains, or dirt present on the clothing to preserve this potential evidence. The correct answer highlights the legal importance of preserving the clothing for potential legal implications. Choice B is related but does not emphasize the legal aspect explicitly. Choice C is vague in mentioning further investigation without specifying the legal significance. Choice D focuses more on forensic analysis rather than the legal implications of preserving the clothing.

4. A patient has been diagnosed with Guillain-Barre Syndrome. Which of the following statements is the most applicable when discussing the impairments with Guillain-Barre Syndrome with the patient?

• A. Guillain-Barre Syndrome improves in almost all cases within 5 years.
• B. Guillain-Barre Syndrome causes limited sensation in the abdominal region.
• C. Guillain-Barre Syndrome causes muscle weakness in the legs.
• D. Guillain-Barre Syndrome affects breathing in severe cases.

Correct answer: C

Rationale: The correct statement is that Guillain-Barre Syndrome causes muscle weakness in the legs. This muscle weakness typically starts in the legs and can progress to the upper body. Choice A is incorrect as while most cases do improve, the recovery time can vary. Choice B is incorrect as Guillain-Barre Syndrome primarily affects muscle weakness rather than sensation. Choice D is incorrect as severe cases of Guillain-Barre Syndrome can lead to respiratory muscle weakness, impacting breathing.

5. A patient 3 hours post-op from a hysterectomy is complaining of intense pain at the incision site. When assessing the patient, the nurse notes a BP of 169/93, pulse 145 bpm, and regular. What action should the nurse take?

• A. Reassure the patient that pain is normal following surgery.
• B. Administer prn Nifedipine and assess the client's response.
• C. Administer prn Meperidine HCL and assess the client's response.
• D. Recheck BP and pulse rate every 20 minutes for the next hour.

Correct answer: C

Rationale: The correct action for the nurse to take in this situation is to administer prn Meperidine HCL and assess the client's response. A BP of 169/93 and a pulse of 145 bpm indicate pain-related hypertension and sinus tachycardia, which are physiological responses to pain. Treating the cause of the increased pulse rate requires pain medication. Reassuring the patient about normal post-surgery pain is important, but addressing the physiological responses to pain is a priority. Administering Nifedipine, a calcium channel blocker, is not indicated for pain management but for hypertension. Rechecking the BP and pulse rate without addressing the pain directly does not address the underlying issue causing the elevated vital signs.

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