Nursing Elites

1. The nurse is caring for a 73-year-old man with cirrhosis. Which data obtained by the nurse during the assessment will be of most concern?

• A. The patient complains of right upper-quadrant pain upon palpation.
• B. The patient's hands flap back and forth when the arms are extended.
• C. The patient has ascites and a 2-kg weight gain from the previous day.
• D. The patient's skin has multiple spider-shaped blood vessels on the abdomen.

Correct answer: B

Rationale: The most concerning data obtained by the nurse is the patient's hands flapping back and forth when the arms are extended, indicating asterixis, which is associated with hepatic encephalopathy. This condition can progress to hepatic coma and requires immediate attention. The presence of spider angiomas and right upper-quadrant abdominal pain are common findings in cirrhosis and do not warrant urgent intervention. Although ascites and weight gain suggest the need for treatment, they are not as alarming as the neurologic manifestations seen in hepatic encephalopathy.

2. A female patient is prescribed metformin for glucose control. The patient is on NPO status pending a diagnostic test. The nurse is most concerned about which side effect of metformin?

• A. Diarrhea and Vomiting
• B. Dizziness and Drowsiness
• C. Metallic taste
• D. Hypoglycemia

Correct answer: D

Rationale: The correct answer is 'Hypoglycemia.' When a patient is on NPO status (nothing by mouth) and prescribed metformin, there is an increased risk of hypoglycemia due to the absence of oral intake. Metformin, as an anti-glycemic drug, can lower blood sugar levels, and without food intake, the risk of hypoglycemia is higher. Diarrhea and vomiting are common gastrointestinal side effects of metformin but are not the main concern in this scenario. Dizziness and drowsiness are potential side effects of some medications but are not typically associated with metformin. Metallic taste is a known side effect of metformin but is not the primary concern in this situation where hypoglycemia is more critical to monitor due to the patient's NPO status.

3. The clinic nurse reviews the record of an infant and notes that the primary health care provider (PHCP) has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the mother to seek health care for the infant?

• A. Diarrhea
• B. Projectile vomiting
• C. Regurgitation of feedings
• D. Constipation

Correct answer: C

Rationale: Hirschsprung's disease, also known as congenital aganglionosis or aganglionic megacolon, is characterized by the absence of ganglion cells in the rectum and other parts of the affected intestine. Clinical manifestations of Hirschsprung's disease include chronic constipation with pellet-like or ribbon-like foul-smelling stools, delayed or absent passage of meconium in the neonatal period, bowel obstruction (especially in the neonatal period), abdominal pain and distention, and failure to thrive. In the case of an infant with suspected Hirschsprung's disease, regurgitation of feedings is a sign that may have led the mother to seek healthcare. This symptom can be associated with the bowel dysfunction and obstruction seen in Hirschsprung's disease. Options A, B, and D are not typically associated with Hirschsprung's disease. Diarrhea is not a common symptom, projectile vomiting is not a typical presentation, and constipation, while a symptom of the disease, is not the sign that would most likely prompt a visit to seek healthcare in an infant suspected of having Hirschsprung's disease.

4. When teaching the client with tuberculosis about follow-up home care, the nurse should emphasize that a laboratory appointment for which of the following lab tests is critical?

• A. Liver function
• B. Kidney function
• C. Blood sugar
• D. Cardiac enzymes

Correct answer: A

Rationale: The nurse should emphasize the importance of monitoring liver function tests in clients taking INH due to the risk of hepatocellular injury and hepatitis associated with this medication. Regular assessment of liver enzymes can help detect liver damage early. Monitoring kidney function, blood sugar levels, or cardiac enzymes is not specifically required for clients taking INH and tuberculosis treatment.

5. When caring for an asthmatic patient with an early-phase reaction, which of the following is indicative of an early-phase reaction?

• A. Rapid bronchospasms
• B. Inflammatory epithelial lesions
• C. Increased secretions
• D. Increased mucosal edema

Correct answer: A

Rationale: Rapid bronchospasms are a symptom of an early-phase reaction in an asthmatic patient. During the early phase, bronchospasms occur due to immediate hypersensitivity reactions. Inflammatory epithelial lesions, increased secretions, and increased mucosal edema are typically seen in late-phase reactions as part of the inflammatory response that occurs later. Therefore, rapid bronchospasms are most indicative of an early-phase reaction.

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