Nursing Elites

1. What are the expected manifestations of a thrombotic stroke?

• A. Gradual loss of function on one side of the body
• B. Loss of sensation in the affected extremity
• C. Sudden loss of consciousness
• D. Seizures and convulsions

Correct answer: A

Rationale: The correct answer is A: Gradual loss of function on one side of the body. Thrombotic strokes are caused by a clot forming in a blood vessel supplying the brain, leading to a gradual onset of symptoms due to impaired blood flow to specific brain regions. Choices B, C, and D are incorrect because loss of sensation, sudden loss of consciousness, seizures, and convulsions are not typically associated with thrombotic strokes. In a thrombotic stroke, the symptoms develop slowly over time, often over minutes to hours, and include manifestations such as weakness, numbness, or paralysis on one side of the body, along with other symptoms related to the affected brain area.

2. When planning care for a patient with diabetes insipidus, what should the nurse include in the plan?

• A. Monitor serum albumin levels
• B. Avoid alcohol
• C. Teach the patient to increase fluids
• D. Increase exercise to reduce stress

Correct answer: B

Rationale: The correct answer is B: 'Avoid alcohol.' Alcohol consumption can exacerbate dehydration in patients with diabetes insipidus, so it is essential to advise them to avoid alcohol. Monitoring serum albumin levels (choice A) is not directly related to managing diabetes insipidus. Teaching the patient to increase fluids (choice C) is not recommended as it can worsen the condition by further diluting the urine. Increasing exercise to reduce stress (choice D) is not a primary intervention for managing diabetes insipidus.

3. What lab value should be prioritized for monitoring in a patient with HIV?

• A. CD4 T-cell count below 180 cells/mm3
• B. Hemoglobin levels
• C. Serum albumin levels
• D. White blood cell count

Correct answer: A

Rationale: The correct answer is A: CD4 T-cell count below 180 cells/mm3. Monitoring CD4 T-cell count is crucial in patients with HIV as it reflects the status of their immune system. A CD4 count below 200 cells/mm3 is indicative of severe immunocompromise, necessitating close monitoring and potential intervention. Choices B, C, and D are less specific to HIV management and do not directly reflect the immune status in these patients. Hemoglobin levels are more relevant for assessing anemia, serum albumin levels for nutritional status, and white blood cell count for overall immune response, but none are as directly tied to HIV disease progression as the CD4 T-cell count.

4. What intervention is needed for continuous bubbling in the chest tube water seal chamber?

• A. Tighten the connections of the chest tube system
• B. Clamp the chest tube
• C. Replace the chest tube system
• D. Continue monitoring the chest tube

Correct answer: A

Rationale: The correct intervention for continuous bubbling in the chest tube water seal chamber is to tighten the connections of the chest tube system. Continuous bubbling indicates an air leak in the system, and tightening the connections can help resolve this issue. Clamping the chest tube (Choice B) is not appropriate and can lead to complications by obstructing the drainage system. Similarly, replacing the entire chest tube system (Choice C) may not be necessary if the issue can be resolved by tightening the connections. Continuing to monitor the chest tube (Choice D) without taking action to address the continuous bubbling may delay necessary interventions to prevent complications.

5. A patient reports abdominal cramping after enema administration. What action should the nurse take to relieve the discomfort?

• A. Lower the height of the solution container
• B. Increase the flow of enema solution
• C. Remove the enema tubing
• D. Stop the procedure

Correct answer: A

Rationale: The correct action to relieve abdominal cramping after enema administration is to lower the height of the solution container. This adjustment slows down the flow rate of the enema solution, which can help reduce discomfort by decreasing the pressure on the patient's abdomen. Increasing the flow of the enema solution (Choice B) would exacerbate the cramping by introducing more solution quickly. Removing the enema tubing (Choice C) is not necessary to address the cramping, and stopping the procedure (Choice D) may not be needed if adjusting the height of the solution container can resolve the issue.

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