Nursing Elites

1. Which goal is a priority for a client with a DSM-IV-TR diagnosis of delirium and the nursing diagnosis Acute confusion related to recent surgery secondary to traumatic hip fracture?

• A. The client will complete activities of daily living.
• B. The client will maintain safety.
• C. The client will remain oriented.
• D. The client will understand communication.

Correct answer: B

Rationale: The correct answer is B: 'The client will maintain safety.' For a client with delirium, especially in the context of acute confusion post-surgery, safety is the top priority. Delirium can lead to disorientation, impaired decision-making, and increased risk of falls or accidents. Ensuring the client's safety by implementing measures to prevent harm is crucial. Choices A, C, and D are important but not the priority in this scenario. Completing activities of daily living, remaining oriented, and understanding communication are relevant goals but come after ensuring the client's safety in the presence of delirium and acute confusion.

2. What is the primary role of albumin in the blood?

• A. Transport oxygen throughout the body.
• B. Serve as a key clotting factor.
• C. Maintain osmotic pressure and fluid balance.
• D. Act as an immune response molecule.

Correct answer: C

Rationale: The correct answer is C: Maintain osmotic pressure and fluid balance. Albumin plays a crucial role in maintaining osmotic pressure by helping to retain fluid within the blood vessels. This function is essential for regulating blood volume and preventing fluid from leaking out into tissues. Choices A, B, and D are incorrect because albumin is not primarily responsible for transporting oxygen, acting as a clotting factor, or functioning as an immune response molecule in the blood.

3. A client with a history of hypertension presents with a severe headache and blurred vision. What is the nurse's priority action?

• A. Administer pain relief medication.
• B. Obtain a stat head CT scan.
• C. Administer antihypertensive medications as prescribed.
• D. Call the healthcare provider immediately.

Correct answer: C

Rationale: The correct answer is to administer antihypertensive medications as prescribed. In a client with a history of hypertension presenting with severe headache and blurred vision, these symptoms could indicate a hypertensive crisis. The priority action is to lower the blood pressure promptly to prevent complications such as stroke, heart attack, or organ damage. Administering antihypertensive medications is crucial in this situation. Administering pain relief medication (Choice A) may temporarily alleviate symptoms but does not address the underlying issue of elevated blood pressure. Obtaining a stat head CT scan (Choice B) may be necessary to rule out other causes but should not delay the administration of antihypertensive medications. Calling the healthcare provider immediately (Choice D) is important but may not address the immediate need to lower blood pressure in a hypertensive crisis.

4. A 45-year-old diabetic male is experiencing erectile dysfunction. If his erectile dysfunction is caused by the nervous system, then the nurse can educate the client that the venous blood supply to the penis is controlled by:

• A. Sympathetic nerves.
• B. Parasympathetic nerves.
• C. Somatic nerves.
• D. Spinal reflexes.

Correct answer: B

Rationale: Erectile function is primarily controlled by the parasympathetic nervous system, which facilitates the dilation of blood vessels in the penis. The parasympathetic nerves are responsible for vasodilation in the penis, allowing blood to enter and creating an erection. Sympathetic nerves, on the other hand, are responsible for ejaculation by causing contraction of the muscles around the vas deferens. Somatic nerves are involved in sensation and movement, not specifically in controlling blood supply to the penis. Spinal reflexes can play a role in the erectile process, but they are not directly responsible for controlling the venous blood supply.

5. A patient receiving isoniazid (INH) and rifampin (Rifadin) has a decreased urinary output and decreased sensation in his great toes. Which laboratory values should be assessed?

• A. Hematocrit and hemoglobin
• B. ALT and AST
• C. Urine culture and sensitivity
• D. Erythrocyte count and differential

Correct answer: C

Rationale: In a patient receiving isoniazid (INH) and rifampin (Rifadin) with symptoms of decreased urinary output and decreased sensation in great toes, assessing urine culture and sensitivity is crucial. These symptoms could indicate peripheral neuropathy, a known side effect of isoniazid, and rifampin can cause renal toxicity. Checking for any urinary tract infection or drug-induced nephrotoxicity is important. Choices A, B, and D are incorrect as they do not directly address the symptoms presented by the patient or the potential side effects of the medications mentioned.

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