Nursing Elites

1. Which client requires careful nursing assessment for signs and symptoms of hypomagnesaemia?

• A. A young adult client with intractable vomiting due to food poisoning
• B. A client who developed hyperparathyroidism in late adolescence
• C. A middle-aged male client in renal failure following an unsuccessful kidney transplant
• D. A female client who excessively consumes simple carbohydrates

Correct answer: C

Rationale: The correct answer is C. Clients in renal failure are at high risk for hypomagnesemia due to their impaired kidney function. Renal failure can lead to decreased excretion of magnesium, resulting in its buildup in the body and potential hypomagnesemia. This client requires careful nursing assessment for signs and symptoms of hypomagnesemia to prevent complications. Choices A, B, and D are not as directly associated with renal failure and its impact on magnesium levels. Intractable vomiting, hyperparathyroidism, and excessive consumption of simple carbohydrates may have other health implications but are not as strongly linked to hypomagnesemia as renal failure.

2. The nurse is caring for a 10-year-old diagnosed with acute glomerulonephritis. Which outcome is the priority for this child?

• A. Activity tolerance as evidenced by appropriate age-level activities being performed
• B. Absence of skin breakdown as evidenced by intact skin and absence of redness
• C. Maintaining adequate nutritional status as evidenced by stable weight without gain or loss
• D. Maintaining fluid balance as evidenced by a urine output of 1 to 2 ml/kg/hr

Correct answer: D

Rationale: In acute glomerulonephritis, maintaining fluid balance is the priority to prevent complications like fluid overload or dehydration. Monitoring urine output within the range of 1 to 2 ml/kg/hr is crucial in assessing renal function. While activity tolerance, skin integrity, and nutritional status are important aspects of care, fluid balance takes precedence due to its direct impact on the renal condition and overall health outcome for the child.

3. A client admitted to the hospital for depression is escorted to a private room. Prior to leaving the room, what intervention is most important for the nurse to implement?

• A. Explain the program's guidelines
• B. Search all personal belongings
• C. Initiate psychosocial assessment
• D. Review the healthcare provider's prescription

Correct answer: B

Rationale: Searching personal belongings is essential to ensure the safety of the client by preventing access to items that could be used for self-harm. While explaining the program's guidelines (Choice A) and initiating a psychosocial assessment (Choice C) are important aspects of care, the immediate concern in this situation is the safety of the client. Reviewing the healthcare provider's prescription (Choice D) is important for providing appropriate treatment but is not as urgent as ensuring the client's safety.

4. When the nurse enters the room to change the dressing of a male client with cancer, he asks, 'Have you ever been with someone when they died?' What is the nurse's best response to him?

• A. Yes, I have. Do you have some questions about dying?
• B. Several times. Now, let's get your dressing changed.
• C. A few times. It was peaceful and there was no pain.
• D. Yes, but you're doing great. Are you concerned about dying?

Correct answer: A

Rationale: The correct response is to acknowledge the client's question and open the door for further discussion by asking if they have questions about dying. This approach allows the nurse to address the client's concerns and fears, promoting open communication and providing emotional support. Choices B and C do not encourage further dialogue about the client's feelings and concerns regarding death. Choice D briefly acknowledges the question but does not actively invite the client to express their thoughts and emotions regarding dying.

5. Which assessment finding should indicate to the nurse that a client with arterial hypertension is experiencing a cardiac complication?

• A. Complaints of an occipital headache
• B. A palpable dorsal pedis pulse bilaterally
• C. Complaints of shortness of breath on exertion
• D. A blood pressure of 160/90

Correct answer: C

Rationale: The correct answer is C, complaints of shortness of breath on exertion. This symptom is indicative of heart failure, a common cardiac complication of arterial hypertension. Shortness of breath on exertion is often due to the heart's inability to pump effectively, leading to fluid buildup in the lungs. Choices A, B, and D are incorrect because complaints of an occipital headache, a palpable dorsal pedis pulse bilaterally, and a blood pressure of 160/90 do not specifically indicate a cardiac complication in a client with arterial hypertension.

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