Nursing Elites

1. What assessment data should lead the nurse to suspect that a client has progressed from HIV infection to AIDS?

• A. Enlarged and tender cervical lymph nodes
• B. Presence of low-grade fever and sore throat
• C. Recent history of recurrent pneumonia
• D. CD4 blood cell count of 300

Correct answer: C

Rationale: The correct answer is C: 'Recent history of recurrent pneumonia.' Recurrent pneumonia is a hallmark indicator of progression to AIDS in clients with HIV infection. It signifies advanced immunosuppression when the body is unable to fight off infections effectively. Enlarged and tender cervical lymph nodes (Choice A) are more indicative of local infections or inflammation rather than AIDS progression. The presence of a low-grade fever and sore throat (Choice B) may be common in various infections and are not specific to AIDS progression. While a CD4 blood cell count of 300 (Choice D) is below the normal range and indicates immunosuppression, it alone may not be sufficient to suspect progression to AIDS without other supporting indicators like opportunistic infections such as recurrent pneumonia.

2. A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h are prescribed. What action should the nurse include in this client’s plan of care?

• A. Perform fingerstick glucose assessment q6h with meals
• B. Mix bedtime dose of insulin glargine with insulin aspart sliding scale dose
• C. Review proper foot care and prevention of injury with the client
• D. Avoid contaminating the insulin aspart for IV use

Correct answer: A

Rationale: Performing fingerstick glucose assessments q6h with meals is essential in monitoring the client's blood glucose levels closely, especially when managing hyperglycemic episodes and adjusting insulin doses with a sliding scale. This action helps in determining the effectiveness of the prescribed insulin regimen. Reviewing proper foot care and preventing injury is important for long-term diabetic management but not the immediate priority in this scenario. Mixing insulin glargine with insulin aspart is not recommended, as they are different types of insulin with distinct mechanisms of action. Ensuring the availability of insulin aspart for IV use is not relevant to the client's current care plan.

3. After assessing an older adult with a suspected cerebrovascular accident (CVA), the nurse documents the client's right upper arm weakness and slurred speech. When the client complains of a severe headache and nausea, and the neurological assessment remains unchanged, which action should the nurse implement first?

• A. Administer an oral analgesic with antiemetic
• B. Collect blood for coagulation times
• C. Send the client for a computed tomography scan of the brain
• D. Obtain a history of medication use, recent surgery, or injury

Correct answer: C

Rationale: In this scenario, the priority action for the nurse is to send the client for a computed tomography (CT) scan of the brain. A CT scan is crucial in assessing acute changes or bleeding that could influence treatment decisions in a suspected cerebrovascular accident (CVA). While addressing symptoms like headache and nausea is important, ruling out acute changes in the brain with a CT scan takes precedence in this situation. Collecting blood for coagulation times may be necessary but is not the initial priority. Obtaining a history of medication use, recent surgery, or injury is also important but not the first action to take when a CVA is suspected.

4. In preparing a care plan for a client admitted with a diagnosis of Guillain-Barre syndrome, which nursing problem has the highest priority?

• A. Ineffective coping related to uncertainty of disease progression
• B. Imbalanced nutrition: less than body requirements related to impaired swallowing reflex
• C. Ineffective breathing pattern related to ascending paralysis
• D. Impaired physical mobility related to asymmetrical descending paralysis

Correct answer: C

Rationale: Ineffective breathing pattern is the highest priority nursing problem for a client with Guillain-Barre syndrome due to the potential risk of respiratory failure. As the paralysis ascends, it can affect the muscles needed for breathing, leading to respiratory compromise. Addressing this problem promptly is crucial to prevent respiratory distress and failure. Choices A, B, and D are also important nursing problems in Guillain-Barre syndrome, but ensuring effective breathing takes precedence over coping, nutrition, and mobility due to the immediate threat it poses to the client's life.

5. A client is admitted to the labor and delivery unit in early labor, and the nurse assesses the status of her contractions. The frequency of contractions is most accurately evaluated by counting the minutes and seconds in which manner?

• A. From the peak of one contraction to the peak of the next contraction
• B. From the beginning of one contraction to the end of that contraction
• C. From the beginning of one contraction to the beginning of the next contraction
• D. From the end of one contraction to the beginning of the next contraction

Correct answer: C

Rationale: The frequency of contractions is measured from the beginning of one contraction to the beginning of the next contraction. This timing is crucial in determining the progress of labor. Choice A, measuring from peak to peak, is incorrect as it assesses the duration between the highest points of contractions, which is not how frequency is calculated. Choice B, measuring from the beginning to the end of one contraction, is incorrect as it does not consider the start of the next contraction. Choice D, measuring from the end of one contraction to the beginning of the next contraction, is incorrect as it misses the initial onset of the following contraction.

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