Nursing Elites

1. When assessing a client's blood pressure and determining an auscultatory gap, which action should the nurse implement?

• A. Compare the palpated systolic blood pressure with the auscultated pressure
• B. Assess the client for lightheadedness upon standing
• C. Determine if an automated blood pressure reading is consistent with the manual reading
• D. Observe for changes in blood pressure between lying and sitting positions

Correct answer: A

Rationale: When an auscultatory gap is present, comparing the palpated systolic blood pressure with the auscultated pressure is crucial. This helps to accurately measure blood pressure and detect any discrepancies caused by the gap. Assessing for lightheadedness upon standing (choice B) is unrelated to addressing an auscultatory gap. Checking the consistency between automated and manual blood pressure readings (choice C) is important for validation but not specifically for managing an auscultatory gap. Observing blood pressure changes between lying and sitting positions (choice D) is relevant for orthostatic hypotension assessment but not for dealing with an auscultatory gap.

2. The nurse is evaluating a client who has had a mastectomy and is experiencing pain and swelling in the arm on the affected side. What action should the nurse take?

• A. Assess for signs of lymphedema
• B. Encourage the client to perform arm exercises
• C. Provide pain relief through medication
• D. Recommend wearing a compression sleeve

Correct answer: A

Rationale: Assessing for signs of lymphedema is crucial in this situation as it is a common complication following mastectomy. Lymphedema presents as swelling and pain in the affected arm due to compromised lymphatic drainage. By assessing for lymphedema, the nurse can identify the condition early and implement appropriate interventions such as compression sleeves, manual lymphatic drainage, and exercises. Encouraging arm exercises (Choice B) may exacerbate the symptoms if lymphedema is present. While providing pain relief through medication (Choice C) is important, assessing for the underlying cause of pain and swelling takes precedence. Recommending a compression sleeve (Choice D) may be suitable but should come after a thorough assessment for lymphedema to ensure the most effective management plan.

3. During an admission assessment on an HIV positive client diagnosed with Pneumocystis carinii pneumonia (PCP), which symptoms should the nurse carefully observe the client for?

• A. Weight loss exceeding 10 percent of baseline body weight
• B. Altered mental status and tachypnea
• C. Creamy white patches in the oral cavity
• D. Normal ABGs with wet lung sounds in all lung fields

Correct answer: B

Rationale: The correct answer is B: Altered mental status and tachypnea. These symptoms are indicative of PCP and severe HIV progression. Weight loss exceeding 10 percent of baseline body weight (choice A) may be seen in HIV/AIDS but is not specific to PCP. Creamy white patches in the oral cavity (choice C) are characteristic of oral thrush, which is more commonly associated with Candida infections in HIV patients. Normal ABGs with wet lung sounds in all lung fields (choice D) would not be expected with PCP, as it typically presents with hypoxemia and diffuse bilateral infiltrates on chest imaging.

4. When caring for a client with diabetes insipidus (DI), it is most important for the nurse to include frequent assessment for which conditions in the client’s plan of care?

• A. Dry mucous membranes, hypotension
• B. Decreased appetite, headache
• C. Nausea and vomiting, muscle weakness
• D. Elevated blood pressure, petechiae

Correct answer: A

Rationale: Dry mucous membranes and hypotension are key indicators of dehydration in clients with diabetes insipidus. The excessive urination associated with DI can lead to fluid loss, resulting in dehydration. Therefore, monitoring for signs such as dry mucous membranes and hypotension is crucial to assess the client's hydration status. Choices B, C, and D are not directly related to the characteristic symptoms of DI and are less relevant in the context of this condition. Decreased appetite and headache (Choice B) are nonspecific symptoms that may occur in various conditions. Nausea, vomiting, and muscle weakness (Choice C) are not typical manifestations of DI. Elevated blood pressure and petechiae (Choice D) are not commonly associated with DI; instead, hypotension is more commonly observed due to volume depletion.

5. An adult male is admitted to the psychiatric unit from the emergency department because he is in the manic disorder. He has lost 10 pounds in the last two weeks and has not bathed in a week because he has been “trying to start a new business” and is “too busy to eat.” He is alert and oriented to time, place and person, but not situation. Which nursing diagnosis has the greatest priority?

• A. Self-care deficit
• B. Disturbed sleep pattern
• C. Disturbed thought processes
• D. Imbalanced nutrition

Correct answer: D

Rationale: Imbalanced nutrition is the priority in this case as the patient has lost a significant amount of weight and is neglecting self-care, such as bathing and eating properly. The weight loss indicates a serious issue that needs immediate attention to prevent further health complications. While self-care deficit, disturbed sleep pattern, and disturbed thought processes are also concerns for this patient, addressing the imbalanced nutrition takes precedence due to the potential impact on the patient's physical health. Neglecting proper nutrition can lead to serious complications, so it is crucial to address this issue first.

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