Nursing Elites

1. The PN determines that a client with cirrhosis is experiencing peripheral neuropathy. What action should the PN take?

• A. Protect the client's feet from injury
• B. Apply a heating pad to the affected area
• C. Keep the client's feet elevated
• D. Assess the feet and legs for jaundice

Correct answer: A

Rationale: Protecting the client's feet from injury is the most appropriate action for a client with cirrhosis experiencing peripheral neuropathy. Peripheral neuropathy can lead to a loss of sensation, making the client prone to unnoticed injuries. Applying a heating pad (Choice B) is contraindicated as it may cause burns or further damage to the affected area. Keeping the client's feet elevated (Choice C) is not directly related to managing peripheral neuropathy and may not provide significant benefit. Assessing the feet and legs for jaundice (Choice D) is important for monitoring liver function in clients with cirrhosis, but in this case, the priority is to prevent injury to the feet due to decreased sensation.

2. The nurse is providing care for a client with type 1 diabetes mellitus who is receiving NPH insulin. The nurse notices that the client's evening glucose levels are consistently above 260 mg/dl. What does this indicate?

• A. States that her feet are constantly cold and feel numb
• B. A wound on the ankle that starts to drain and becomes painful
• C. Consecutive evening serum glucose greater than 260 mg/dl
• D. Reports nausea in the morning but still able to eat breakfast

Correct answer: C

Rationale: High evening glucose levels suggest that the current insulin dosage may be inadequate to control the client's blood sugar levels effectively. This indicates poor glycemic control and the need for a possible adjustment in the insulin regimen. Option A describes symptoms of peripheral neuropathy, which are not directly related to the elevated glucose levels but may be a long-term complication of diabetes. Option B describes a wound infection, which is not directly related to the client's high glucose levels. Option D mentions morning nausea, which could be due to various causes and is not directly related to the high evening glucose levels.

3. What is the function of the epiglottis during swallowing?

• A. Prevents food from entering the trachea
• B. Aids in food propulsion
• C. Enhances taste sensation
• D. Lubricates the esophagus

Correct answer: A

Rationale: The epiglottis is a flap of tissue that closes over the trachea during swallowing to prevent food and liquids from entering the airway. Choice A is correct because the primary function of the epiglottis is to act as a lid over the trachea, ensuring that food goes down the esophagus and not into the windpipe. Choices B, C, and D are incorrect as they do not describe the specific role of the epiglottis during swallowing.

4. What is the most common cause of hyperthyroidism?

• A. Graves' disease
• B. Hashimoto's thyroiditis
• C. Thyroid nodules
• D. Pituitary adenoma

Correct answer: A

Rationale: Corrected Rationale: Graves' disease is the most common cause of hyperthyroidism. It is characterized by an overactive thyroid gland due to autoantibodies stimulating the thyroid. Hashimoto's thyroiditis is actually a cause of hypothyroidism, not hyperthyroidism. Thyroid nodules and pituitary adenoma are not common causes of hyperthyroidism.

5. A client is recovering from a right-sided mastectomy and is concerned about lymphedema. What should the nurse include in the discharge teaching to minimize this risk?

• A. Encourage wearing tight clothing on the affected arm.
• B. Advise against lifting heavy objects with the affected arm.
• C. Recommend the client sleep on the affected side.
• D. Suggest frequent massage of the affected arm.

Correct answer: B

Rationale: The correct answer is B: Advise against lifting heavy objects with the affected arm. Lifting heavy objects with the affected arm can increase the risk of lymphedema. It is important for clients to avoid activities that strain the affected arm to minimize the risk of developing lymphedema. Choices A, C, and D are incorrect because wearing tight clothing on the affected arm, sleeping on the affected side, and frequent massage of the affected arm can potentially worsen lymphedema or impede the recovery process. Tight clothing can impede lymphatic flow, sleeping on the affected side can restrict circulation, and frequent massage can exacerbate swelling in the arm.

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