Nursing Elites

1. Which nursing diagnosis is commonly used among patients affected by fibromyalgia?

• A. Decreased self-care in activities of daily living related to fatigue
• B. Impaired mental functioning related to electrolyte imbalances
• C. Increased vigilance secondary to electrolyte imbalances
• D. At risk for a swallowing disorder related to fibromyalgia

Correct answer: A

Rationale: The correct answer is A: 'Decreased self-care in activities of daily living related to fatigue.' Patients with fibromyalgia commonly experience fatigue, which can lead to decreased ability to perform self-care activities. This nursing diagnosis addresses a direct consequence of fibromyalgia. Choices B, C, and D are incorrect because they do not directly correlate with the common manifestations of fibromyalgia. Impaired mental functioning related to electrolyte imbalances and increased vigilance secondary to electrolyte imbalances are not typical presentations of fibromyalgia. 'At risk for a swallowing disorder related to fibromyalgia' is not a common nursing diagnosis associated with fibromyalgia; swallowing disorders are not a primary symptom of this condition.

2. What is the softening and thinning of the cervix during labor known as?

• A. Dilation
• B. Symphysis
• C. Effacement
• D. Hyperplasia

Correct answer: C

Rationale: Effacement is the correct term for the softening and thinning of the cervix during labor. It is the process where the cervix becomes thinner, allowing it to stretch and open as labor progresses. Choice A, 'Dilation,' is incorrect as it refers to the opening of the cervix. Choice B, 'Symphysis,' is incorrect as it refers to the joint that connects the two pubic bones. Choice D, 'Hyperplasia,' is incorrect as it refers to an increase in the number of cells in an organ or tissue.

3. Dr. Shrunk orders intravenous (IV) insulin for Rita, a client with a blood sugar of 563. Nurse AJ administers insulin lispro (Humalog) intravenously (IV). What does the best evaluation of the nurse reveal? Select one that does not apply.

• A. The nurse could have given the insulin subcutaneously.
• B. The nurse did not have to contact the physician.
• C. The nurse should have used regular insulin (Humulin R).
• D. The nurse used the correct insulin.

Correct answer: C

Rationale: The best evaluation of the nurse reveals that she should have used regular insulin (Humulin R) for IV administration. Regular insulin is the only insulin approved for intravenous administration due to its pharmacokinetic properties. Insulin lispro (Humalog) is not suitable for IV use. Choice A is incorrect because giving insulin intravenously is necessary in this case of high blood sugar. Choice B is incorrect because administering a different insulin without consulting the physician is not appropriate. Choice D is incorrect because the nurse used the incorrect insulin, which could pose risks to the client's health.

4. Which of the following assessment tools is used to determine the patient's level of consciousness?

• A. The Snellen Scale
• B. The Norton Scale
• C. The Morse Scale
• D. The Glasgow Scale

Correct answer: D

Rationale: The correct answer is D, The Glasgow Scale. The Glasgow Coma Scale is specifically designed to assess a patient's level of consciousness by evaluating eye opening, verbal response, and motor response. Choices A, B, and C are incorrect because the Snellen Scale is used for vision testing, the Norton Scale is used for assessing the risk of pressure sores, and the Morse Scale is used for evaluating a patient's risk of falling, not for determining the level of consciousness.

5. Select the stage of shock that is accurately paired with its characteristic.

• A. The initial stage of shock: Hyperventilation occurs and the blood pH rises.
• B. The compensatory stage of shock: Hypoxia occurs and lactic acid rises.
• C. The progressive stage of shock: Histamine is released; fluid and proteins leak into surrounding tissues and the blood thickens.
• D. The refractory stage of shock: Potassium ions leak out; sodium ions build up, and metabolic acidosis increases.

Correct answer: C

Rationale: The progressive stage of shock is accurately described as the stage where histamine is released, leading to fluid and proteins leaking into surrounding tissues and the blood thickening. In this stage, the body's compensatory mechanisms are overwhelmed, resulting in a cascade of events that worsen the shock state. Choice A is incorrect as hyperventilation and a rise in blood pH are more characteristic of the compensatory stage. Choice B is incorrect as hypoxia and a rise in lactic acid are more typical of the progressive stage. Choice D is incorrect as the described electrolyte imbalances and metabolic acidosis are more aligned with the refractory stage of shock.

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