Nursing Elites

1. The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding?

• A. Nuchal rigidity
• B. Carotid bruit
• C. Jugular vein distention
• D. Palpable cervical lymph node

Correct answer: B

Rationale: The correct answer is B: Carotid bruit. A carotid bruit is a significant risk factor for stroke as it indicates turbulent blood flow due to narrowing of the carotid artery. Nuchal rigidity is associated with meningitis, jugular vein distention can be a sign of heart failure, and palpable cervical lymph nodes may indicate infection, but they are not directly linked to stroke risk.

2. Which is a long-term complication of cleft lip and palate?

• A. Cognitive impairment
• B. Altered growth and development
• C. Faulty dentition
• D. Physical abilities

Correct answer: C

Rationale: The correct answer is C, 'Faulty dentition.' The older child with cleft lip and palate may experience psychological difficulties due to the cosmetic appearance of the defect, issues with impaired speech, and faulty dentition. This can lead to problems with dental alignment, crowding, missing or malformed teeth, and other dental issues. Choices A, B, and D are incorrect as cognitive impairment, altered growth and development, and physical abilities are not typically considered long-term complications of cleft lip and palate.

3. Which pathology is associated with an asthma condition?

• A. Chronic dilation and inflammation of the bronchi.
• B. Recurrent spasms of the airways accompanied by edema and mucus production.
• C. Progressive loss of lung function due to destruction of alveolar walls.
• D. Infection of the lung parenchyma.

Correct answer: B

Rationale: The correct answer is B: Recurrent spasms of the airways accompanied by edema and mucus production. Asthma is characterized by bronchospasms, inflammation, swelling of the airways, and increased mucus production. This leads to airway constriction, making it difficult to breathe. Choices A, C, and D do not represent the typical pathology seen in asthma. Chronic dilation and inflammation of the bronchi (Choice A) is more characteristic of bronchiectasis, progressive loss of lung function due to destruction of alveolar walls (Choice C) is seen in conditions like emphysema, and infection of the lung parenchyma (Choice D) is more related to conditions like pneumonia.

4. Which nursing diagnosis should be selected for a client who is receiving thrombolytic infusions for treatment of an acute myocardial infarction?

• A. Risk for infection related to thrombolysis.
• B. Risk for fluid volume deficit related to thrombolysis.
• C. Risk for impaired skin integrity related to thrombolysis.
• D. Risk for injury related to effects of thrombolysis.

Correct answer: D

Rationale: Thrombolytic therapy increases the risk of bleeding, not infection, fluid volume deficit, or impaired skin integrity. The most significant concern with thrombolytic therapy is the potential for bleeding complications, which can lead to various injuries. Therefore, 'Risk for injury related to effects of thrombolysis' is the most appropriate nursing diagnosis in this scenario. Choices A, B, and C are incorrect as they do not directly correlate with the primary risk associated with thrombolytic therapy.

5. Following surgical repair of the bladder, a female client is being discharged from the hospital to home with an indwelling urinary catheter. Which instruction is most important for the nurse to provide to this client?

• A. Avoid coiling the tubing and keep it free of kinks.
• B. Cleanse the perineal area with soap and water twice daily.
• C. Keep the drainage bag lower than the level of the bladder.
• D. Drink 1,000 ml of fluids daily to irrigate the catheter.

Correct answer: C

Rationale: The most crucial instruction for a client with an indwelling urinary catheter post-bladder surgery is to keep the drainage bag positioned lower than the level of the bladder. This positioning prevents backflow of urine into the bladder, reducing the risk of infection. Choice A, avoiding coiling the tubing and keeping it free of kinks, is important to maintain proper flow but not as critical as ensuring the drainage bag is lower than the bladder. Choice B, cleansing the perineal area, is essential for overall hygiene but not directly related to catheter care instructions. Choice D, drinking fluids to irrigate the catheter, is not recommended as it may increase the risk of infection and should be guided by healthcare providers based on specific needs.

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