Nursing Elites

1. When providing care for an unconscious client who has seizures, which nursing intervention is most essential?

• A. Ensure oral suction is available.
• B. Maintain the client in a semi-Fowler's position.
• C. Provide frequent mouth care.
• D. Keep the room at a comfortable temperature.

Correct answer: A

Rationale: During seizures in an unconscious client, ensuring oral suction is available is crucial to managing secretions and preventing aspiration. This intervention helps maintain a clear airway and reduce the risk of complications. Maintaining the client in a semi-Fowler's position (Choice B) may be important for airway management but is not as critical as having oral suction ready. Providing frequent mouth care (Choice C) and keeping the room at a comfortable temperature (Choice D) are important aspects of overall care but are not as urgently needed as ensuring oral suction for managing secretions during seizures.

2. A middle-aged male client with diabetes continues to eat an abundance of foods that are high in sugar and fat. According to the Health Belief Model, which event is most likely to increase the client's willingness to become compliant with the prescribed diet?

• A. He visits his diabetic brother who just had surgery to amputate an infected foot.
• B. He is provided with the most current information about the dangers of untreated diabetes.
• C. He comments on the community service announcements about preventing complications associated with diabetes.
• D. His wife expresses a sincere willingness to prepare meals that are within his prescribed diet.

Correct answer: A

Rationale: According to the Health Belief Model, the most effective event to increase compliance with the prescribed diet for a middle-aged male client with diabetes is experiencing a significant consequence related to the disease. In this case, visiting his diabetic brother who just had surgery to amputate an infected foot would serve as a strong 'cue to action,' increasing the client's perceived seriousness of the disease. This event is likely to have a more immediate and impactful effect on the client than other options. Option B provides valuable information but may not have the same personal and emotional impact as witnessing a severe consequence firsthand. Option C involves indirect exposure to prevention messages, which might not be as compelling as a direct experience. Option D, while supportive, does not present a direct consequence of non-compliance like option A does.

3. When assessing the lower extremities of a client with peripheral vascular disease (PVD), the nurse notes bilateral ankle edema. The edema is related to:

• A. Competent venous valves.
• B. Decreased blood volume.
• C. Increase in muscular activity.
• D. Increased venous pressure.

Correct answer: D

Rationale: The correct answer is 'Increased venous pressure.' In peripheral vascular disease (PVD), impaired blood flow leads to increased venous pressure in the lower extremities, causing fluid to leak out of the blood vessels and accumulate as edema. Choice A, 'Competent venous valves,' is incorrect because in PVD, the venous valves may be incompetent, contributing to venous pooling and edema. Choice B, 'Decreased blood volume,' is incorrect as PVD is associated with impaired blood flow rather than reduced blood volume. Choice C, 'Increase in muscular activity,' is incorrect as it does not directly relate to the development of edema in PVD.

4. A 32-year-old female client complains of severe abdominal pain each month before her menstrual period, painful intercourse, and painful defecation. Which additional history should the nurse obtain that is consistent with the client's complaints?

• A. Frequent urinary tract infections.
• B. Inability to get pregnant.
• C. Premenstrual syndrome.
• D. Chronic use of laxatives.

Correct answer: B

Rationale: The correct answer is B: 'Inability to get pregnant.' The symptoms described in the client's complaints, which include severe abdominal pain before menstruation, painful intercourse, and painful defecation, are indicative of endometriosis. Endometriosis is a condition characterized by the abnormal presence of endometrial tissue outside the uterus, commonly leading to infertility. While choices A, C, and D may be associated with other conditions, they are not directly related to the symptoms described by the client, making them incorrect choices. Frequent urinary tract infections may suggest a different issue, premenstrual syndrome does not typically present with severe abdominal pain, and chronic use of laxatives is not a typical symptom of endometriosis.

5. A client with renal insufficiency and a low red blood cell count asks, 'Is my anemia related to the renal insufficiency?' How should the nurse respond?

• A. Red blood cells produce erythropoietin, which increases blood flow to the kidneys.
• B. Your anemia and renal insufficiency are related to inadequate vitamin D and a loss of bone density.
• C. Erythropoietin is usually released from the kidneys and stimulates red blood cell production in the bone marrow.
• D. Kidney insufficiency inhibits active transportation of red blood cells throughout the blood.

Correct answer: C

Rationale: The correct answer is C. Erythropoietin is produced in the kidney and is released in response to decreased oxygen tension in the renal blood supply. Erythropoietin stimulates red blood cell production in the bone marrow. Anemia in renal insufficiency is often due to decreased erythropoietin production. Anemia and renal insufficiency are not manifestations of vitamin D deficiency as stated in choice B. Choice A is incorrect as erythropoietin does not increase blood flow to the kidneys. Choice D is incorrect because kidney insufficiency does not inhibit active transportation of red blood cells throughout the blood; rather, it affects erythropoietin production and subsequent red blood cell formation.

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