Nursing Elites

1. In conducting a health assessment for a family with a history of cardiovascular disease, which family member should be prioritized for further evaluation and intervention?

• A. a 45-year-old father who smokes and has high cholesterol
• B. a 17-year-old daughter who is overweight and inactive
• C. a 50-year-old mother with a history of hypertension
• D. a 12-year-old son who has a normal weight and is active

Correct answer: A

Rationale: The 45-year-old father who smokes and has high cholesterol is at a higher risk for cardiovascular disease due to multiple risk factors. Smoking and high cholesterol are significant contributors to the development of cardiovascular issues. Prioritizing his evaluation and intervention is crucial to address these modifiable risk factors. The other family members, though they may have risk factors as well, do not present with the same level of immediate risk based on the information provided.

2. A client is suspected of being poisoned and presents with symmetric, descending flaccid paralysis, blurred vision, double vision, and dry mouth. The nurse should consider these findings consistent with which potential bioterrorism agent?

• A. ricin
• B. botulism toxin
• C. sulfur mustard
• D. yersinia pestis

Correct answer: B

Rationale: The correct answer is B: botulism toxin. The symptoms described, including symmetric, descending flaccid paralysis, blurred vision, double vision, and dry mouth, are classic manifestations of botulism, which is caused by a toxin produced by Clostridium botulinum. This toxin affects the nervous system, leading to muscle weakness and paralysis. Choice A, ricin, typically presents with gastrointestinal symptoms and organ failure. Choice C, sulfur mustard, causes blistering skin and respiratory issues. Choice D, yersinia pestis, is associated with the plague and presents with fever, chills, weakness, and swollen lymph nodes.

3. A client with a history of peptic ulcer disease is admitted with sudden severe abdominal pain. Which finding indicates the possibility of a perforated ulcer?

• A. Bowel sounds are hyperactive in all quadrants.
• B. Abdomen is soft and nondistended.
• C. The client reports sudden severe abdominal pain.
• D. Blood pressure of 110/70 mm Hg.

Correct answer: C

Rationale: The correct answer is C. Sudden severe abdominal pain is a key clinical manifestation of a perforated ulcer. The sudden onset of severe pain is concerning for a perforation in the ulcer, which can lead to peritonitis if not promptly addressed. Choices A, B, and D are incorrect because hyperactive bowel sounds, a soft and nondistended abdomen, and a blood pressure of 110/70 mm Hg are not specific indicators of a perforated ulcer. Hyperactive bowel sounds may suggest increased gastrointestinal motility, a soft abdomen may not necessarily indicate a perforation, and a blood pressure of 110/70 mm Hg is within normal limits and does not directly relate to a perforated ulcer.

4. The nurse is caring for a client with Addison's disease. Which finding requires immediate intervention?

• A. Hyperpigmentation of the skin.
• B. Low blood pressure.
• C. Nausea and vomiting.
• D. Hypoglycemia.

Correct answer: B

Rationale: Low blood pressure in a client with Addison's disease requires immediate intervention as it can indicate an Addisonian crisis, a life-threatening condition that necessitates prompt treatment. Hyperpigmentation of the skin is a characteristic finding in Addison's disease but does not require immediate intervention. Nausea and vomiting can be managed symptomatically in Addison's disease. While hypoglycemia needs attention, it is not the most critical finding requiring immediate intervention in this context.

5. A client who is taking clonidine (Catapres, Duraclon) reports drowsiness. Which additional assessment should the nurse make?

• A. How long has the client been taking the medication?
• B. Assess the client's dietary habits.
• C. Check for signs of infection.
• D. Evaluate the client's sleep pattern.

Correct answer: A

Rationale: The correct answer is A. When a client reports drowsiness while taking clonidine, the nurse should assess how long the client has been taking the medication. Drowsiness is a common side effect that can occur in the early weeks of treatment with clonidine. By understanding the duration of medication use, the nurse can determine if the drowsiness is a temporary effect that may decrease over time. Choices B, C, and D are incorrect because assessing the client's dietary habits, checking for signs of infection, or evaluating the client's sleep pattern would not directly address the drowsiness associated with clonidine use.

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