Nursing Elites

1. The nurse is working in a support group for clients with HIV. Which point is most important for the nurse to stress?

• A. They must inform household members of their condition.
• B. They must take their medications exactly as prescribed.
• C. They must abstain from substance use.
• D. They must avoid large crowds.

Correct answer: B

Rationale: The correct answer is that clients with HIV must take their medications exactly as prescribed. Antiretrovirals need to be taken as directed to prevent the development of drug-resistant strains and maintain treatment effectiveness. Missing doses can compromise the effectiveness of future treatments. Choice A, informing household members, is important for social support but not the most critical aspect of managing the condition. Choice C, abstaining from substance use, is important but not as crucial as medication adherence. Choice D, avoiding large crowds, is not directly related to HIV management as long as the individual's immune system is not significantly compromised.

2. A client is brought into the emergency room where the physician suspects that he has cardiac tamponade. Based on this diagnosis, the nurse would expect to see which of the following signs or symptoms in this client?

• A. Fever, fatigue, malaise
• B. Hypotension and distended neck veins
• C. Cough and hemoptysis
• D. Numbness and tingling in the extremities

Correct answer: B

Rationale: Cardiac tamponade occurs when fluid or blood accumulates in the pericardium, preventing the heart from contracting properly. This leads to decreased cardiac output and is considered a medical emergency. Classic signs of cardiac tamponade include hypotension (low blood pressure) and distended neck veins due to the increased pressure around the heart. These signs result from the compromised ability of the heart to pump effectively. Choices A, C, and D are not typically associated with cardiac tamponade. Fever, fatigue, and malaise are non-specific symptoms that can be seen in various conditions. Cough and hemoptysis are more commonly associated with respiratory conditions, while numbness and tingling in the extremities are neurological symptoms not typically seen in cardiac tamponade.

3. Which action should the nurse take to evaluate treatment effectiveness for a patient who has hepatic encephalopathy?

• A. Ask the patient to extend both arms forward.
• B. Request that the patient walk with eyes closed.
• C. Ask the patient to perform the Valsalva maneuver.
• D. Observe the patient's breathing pattern.

Correct answer: B

Rationale: To evaluate treatment effectiveness for a patient with hepatic encephalopathy, requesting the patient to walk with eyes closed is crucial. This test assesses the patient's balance, gait, and coordination, which can be impaired in hepatic encephalopathy due to altered mental status and brain function. Walking with eyes closed challenges the patient's sensory input and proprioception, providing valuable information on improvement or deterioration in neurological function. Asking the patient to extend both arms forward is used to check for asterixis, a sign often seen in hepatic encephalopathy, but it is not specific for evaluating treatment effectiveness. Performing the Valsalva maneuver is unrelated to assessing hepatic encephalopathy and is more commonly used in cardiac evaluations. Observing the patient's breathing pattern may be important in other conditions but is not directly relevant to evaluating treatment effectiveness for hepatic encephalopathy.

4. A 64-year-old patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care?

• A. Assist with active range of motion (ROM).
• B. Observe for agitation and paranoia.
• C. Give muscle relaxants as needed to reduce spasms.
• D. Use simple words and phrases to explain procedures.

Correct answer: A

Rationale: In a patient with ALS, progressive muscle weakness is a significant issue. Assisting with active range of motion (ROM) exercises will help maintain muscle strength for as long as possible. Agitation and paranoia are not typically associated with ALS, making choice B incorrect. Giving muscle relaxants can further weaken muscles and depress respirations, worsening the condition, so choice C is inappropriate. Choice D is not directly related to the patient's physical condition and needs.

5. A child is diagnosed with Hirschsprung's disease. The nurse is teaching the parents about the cause of the disease. Which statement, if made by the parent, supports that teaching was successful?

• A. The absence of special cells in the rectum caused the disease.
• B. Incomplete digestion of the protein part of wheat, barley, rye, and oats is not the cause of the disease.
• C. The disease does not occur due to increased bowel motility leading to spasm and pain.
• D. The disease is not caused by the inability to tolerate sugar found in dairy products.

Correct answer: A

Rationale: Hirschsprung's disease, also known as congenital aganglionosis or megacolon, is characterized by the absence of ganglion cells in the rectum and, sometimes, extending into the colon. Choice A correctly explains the cause of Hirschsprung's disease. Choice B is incorrect as it describes celiac disease, which is related to gluten intolerance. Choice C is inaccurate as it describes symptoms of irritable bowel syndrome, not the cause of Hirschsprung's disease. Choice D is wrong as it pertains to lactose intolerance, not Hirschsprung's disease.

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