Nursing Elites

1. What physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?

• A. Soft, spongy fundus.
• B. Saturating two perineal pads per hour.
• C. Pulse rate of 56 BPM.
• D. Unilateral lower leg pain.

Correct answer: C

Rationale: The correct answer is C. A pulse rate of 56 BPM can be considered a normal finding for a primigravida client who is 12 hours postpartum. Postpartum bradycardia can occur due to increased stroke volume and decreased vascular resistance after delivery. It is important for the nurse to monitor the client's vital signs and recognize that a lower pulse rate can be expected in the immediate postpartum period. Choices A, B, and D are incorrect because a soft, spongy fundus may indicate uterine atony, saturating two perineal pads per hour is excessive bleeding, and unilateral lower leg pain could suggest deep vein thrombosis, all of which would require further assessment and intervention.

2. A 70-year-old woman presents with fatigue, anorexia, and weight loss. She has noticed darkening of her skin, particularly in sun-exposed areas. Laboratory tests reveal hyponatremia, hyperkalemia, and low cortisol levels. What is the most likely diagnosis?

• A. Cushing's syndrome
• B. Addison's disease
• C. Hypothyroidism
• D. Pheochromocytoma

Correct answer: B

Rationale: The combination of symptoms such as fatigue, anorexia, weight loss, hyperpigmentation of the skin, along with hyponatremia, hyperkalemia, and low cortisol levels, points towards Addison's disease. This condition is characterized by adrenal insufficiency, leading to a deficiency in cortisol and aldosterone production.

3. A client with severe rheumatoid arthritis is experiencing joint pain and stiffness. Which intervention should the nurse implement to help relieve the client's symptoms?

• A. Apply cold packs to the affected joints.
• B. Encourage passive range-of-motion exercises.
• C. Administer a muscle relaxant.
• D. Provide a high-calorie diet.

Correct answer: B

Rationale: Encouraging passive range-of-motion exercises is the most appropriate intervention to help relieve symptoms of joint pain and stiffness in clients with severe rheumatoid arthritis. These exercises help maintain joint mobility, prevent muscle contractures, and reduce stiffness in the affected joints. Passive range-of-motion exercises can also improve circulation to the joints, promoting healing and reducing pain. Applying cold packs may help with inflammation and pain temporarily, but it does not address the long-term joint mobility issues associated with rheumatoid arthritis. Muscle relaxants are not typically indicated for managing joint pain and stiffness in rheumatoid arthritis. While nutrition is important for overall health, providing a high-calorie diet is not a direct intervention for relieving joint pain and stiffness in this context.

4. A patient with severe anemia is prescribed erythropoietin. What is the primary action of this medication?

• A. Stimulate white blood cell production
• B. Increase platelet count
• C. Promote red blood cell production
• D. Enhance clotting factor production

Correct answer: C

Rationale: Erythropoietin is a hormone that primarily stimulates the bone marrow to produce more red blood cells. By increasing red blood cell production, erythropoietin helps to improve oxygen delivery to tissues, which is essential in managing anemia. Choices A, B, and D are incorrect because erythropoietin specifically targets red blood cell production and does not have a direct effect on white blood cells, platelets, or clotting factors.

5. A recently widowed middle-aged female client presents to the psychiatric clinic for evaluation and tells the nurse that she has 'little reason to live.' She describes one previous suicidal gesture and admits to having a gun in her home. To maintain the client's confidentiality and to help ensure her safety, which action is best for the nurse to implement?

• A. Encourage the client to remove the gun from her possession.
• B. Notify the client's healthcare provider of the availability of the weapon.
• C. Contact a person of the client's choosing to remove the weapon from the home.
• D. Call the local police department and have the weapon removed from the home.

Correct answer: C

Rationale: In this scenario, it is crucial to maintain the client's confidentiality while ensuring her safety. Contacting a person chosen by the client to remove the weapon from her home is the best course of action. This approach respects the client's autonomy and helps reduce the risk of harm without involving external authorities unnecessarily.

Similar Questions