Nursing Elites

1. The nurse is caring for a client who is dying. While assessing the client for signs of impending death, the nurse observes the client for:

• A. elevated blood pressure.
• B. Cheyne-Stokes respiration.
• C. elevated pulse rate.
• D. decreased temperature.

Correct answer: B

Rationale: Cheyne-Stokes respirations are a pattern of breathing characterized by rhythmic waxing and waning of respirations from very deep to very shallow breathing with periods of temporary apnea. This pattern is often associated with conditions like cardiac failure and can be a sign of impending death. Elevated blood pressure and pulse rate are not typically associated with the dying process. Decreased temperature is also not a common sign of impending death. Therefore, option B, Cheyne-Stokes respiration, is the correct choice when assessing a client for signs of impending death.

2. Which information obtained from the mother of a child with cerebral palsy most likely correlates to the diagnosis?

• A. She was born at 42 weeks gestation.
• B. She had meningitis when she was 6 months old.
• C. She had physiologic jaundice after delivery.
• D. She has frequent sore throats.

Correct answer: B

Rationale: The diagnosis of meningitis at age 6 months correlates to a diagnosis of cerebral palsy. Cerebral palsy, a neurological disorder, is often associated with birth trauma or infections of the brain or spinal column. Answers A, C, and D are not related to the question. Gestational length (choice A) is not a direct risk factor for cerebral palsy. Physiologic jaundice (choice C) and frequent sore throats (choice D) are not typically associated with cerebral palsy.

3. A client visits the clinic after the death of a parent. Which statement made by the client's sister signifies abnormal grieving?

• A. "My sister still has episodes of crying, and it's been 3 months since Daddy died."?
• B. "Sally seems to have forgotten the bad things that Daddy did in his lifetime."?
• C. "She really had a hard time after Daddy's funeral. She said that she had a sense of longing."?
• D. "Sally has not been sad at all about Daddy's death. She acts like nothing has happened."?

Correct answer: D

Rationale: Abnormal grieving is often characterized by a lack of sadness or acknowledgment of the loss. In this scenario, the statement 'Sally has not been sad at all about Daddy's death. She acts like nothing has happened' indicates abnormal grieving as it suggests a lack of emotional response or denial of the death. On the other hand, choices A, B, and C all describe normal grieving reactions: crying episodes, selective memory of the deceased, and feelings of longing after the funeral. These responses are typical in the grieving process. Therefore, choice D is the correct answer, highlighting a potential abnormality in the grieving process.

4. A client is taking hydrocodone (Vicodin) for chronic back pain. The client has required an increase in the dose and asks whether this means he is addicted to Vicodin. The nurse should base her reply on the knowledge that:

• A. the client's body has developed tolerance, requiring more drug to produce the same effect
• B. the client is preoccupied with getting the drug and is experiencing loss of control, indicating drug dependence
• C. addiction involves psychological behaviors related to substance use, not just physical dependence
• D. the client is coping with chronic back pain and requires adjustments in the medication regimen

Correct answer: A

Rationale: When a client requires an increased dose of a drug, such as in this case with hydrocodone, it suggests that the body has developed tolerance to the medication. Tolerance means that the client needs more of the drug to achieve the same effect as before. This does not inherently indicate addiction, which involves psychological behaviors related to substance use. Choice B describes drug dependence, where the client is preoccupied with obtaining the drug and experiences loss of control, which is not the same as tolerance. Choice C correctly points out that addiction is more than just physical dependence with withdrawal symptoms and tolerance; it includes psychological factors. Choice D is irrelevant as it discusses adjusting the medication for pain management, not addressing the client's concern about addiction.

5. A nurse is teaching the mother of an 11-month-old infant how to clean the infant's teeth. The nurse tells the mother to take which action?

• A. Use a small amount of toothpaste and a soft-bristle toothbrush
• B. Use water and a cotton swab and rub the teeth
• C. Use diluted fluoride and rub the teeth with a soft washcloth
• D. Dip the infant's pacifier in maple syrup so that the infant will suck

Correct answer: C

Rationale: The correct action when cleaning an infant's teeth is to use water and a cotton swab to gently rub the teeth. This method helps in removing any food particles or plaque buildup without the risks associated with toothpaste ingestion. Using a small amount of toothpaste and a soft-bristle toothbrush is not recommended for infants as they may swallow the toothpaste, leading to potential fluoride ingestion issues. Using diluted fluoride and rubbing the teeth with a soft washcloth is unnecessary at this age since infants typically receive fluoride through other sources like formula. Dipping the infant's pacifier in maple syrup is highly inappropriate and poses a significant risk of tooth decay due to the high sugar content, which can harm the infant's teeth.

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