Nursing Elites

1. Which action represents the evaluation stage of the plan of care?

• A. The nurse assigns a nursing diagnosis of Impaired Skin Integrity related to diminished skin circulation
• B. The nurse assesses the client's vital signs and asks about symptoms
• C. The nurse determines that the client is not meeting his set outcomes and makes revisions
• D. The nurse discusses the client's health history

Correct answer: C

Rationale: The correct answer is C. The evaluation stage of the nursing process involves reviewing the assessments, diagnoses, and interventions given to the client and then determining if the client is meeting expected outcomes. In this scenario, the nurse is assessing whether the client is meeting the outcomes set for their care plan and making revisions as needed. Choice A is incorrect as assigning a nursing diagnosis is part of the nursing diagnosis phase, not the evaluation phase. Choice B represents the assessment phase of the nursing process, not the evaluation phase. Choice D involves discussing the client's health history, which is more aligned with the assessment phase rather than the evaluation phase.

2. Which of the following is a function of risk management?

• A. To consider the problems that arise if errors happen and their effects on the healthcare environment
• B. To identify how nursing care responds to specific client problems
• C. To view clients as customers and decide what actions will provide a satisfying healthcare experience
• D. To analyze physician-nurse relationships and determine where collaboration efforts can improve

Correct answer: A

Rationale: The function of risk management in healthcare is to assess and address potential risks that could lead to errors and their effects on the healthcare environment. This involves identifying, evaluating, and prioritizing risks to minimize their impact and prevent adverse outcomes. Choice A is correct because it aligns with the core purpose of risk management in healthcare. Choices B, C, and D are incorrect as they do not directly relate to the primary focus of risk management, which is the proactive management of risks to ensure patient safety and quality care.

3. Which of the following conditions may warrant a serum creatinine level?

• A. Rhabdomyolysis
• B. Digitalis toxicity
• C. Glomerulonephritis
• D. All answers are correct

Correct answer: D

Rationale: A serum creatinine level may be warranted in conditions that can affect renal function or cause muscle breakdown. Rhabdomyolysis, characterized by muscle injury and breakdown, can lead to elevated creatinine levels due to the release of creatinine from muscles. Digitalis toxicity can impair renal function, leading to a need for monitoring creatinine levels. Glomerulonephritis, an inflammatory condition affecting the kidney's filtering units, can also impact renal function and require assessment of creatinine levels. Therefore, all the provided conditions may warrant a serum creatinine level to assess renal function and muscle breakdown.

4. A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol) 50 mg bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10 mg HS. Which client behavior would warrant the nurse to administer benztropine?

• A. Tactile hallucinations
• B. Tardive dyskinesia
• C. Restlessness and muscle rigidity
• D. Reports of hearing disturbing voices

Correct answer: C

Rationale: Benztropine (Cogentin) is an anticholinergic medication used to treat extrapyramidal symptoms, such as restlessness and muscle rigidity, which are common side effects of antipsychotic medications like haloperidol. Tactile hallucinations and reports of hearing disturbing voices are symptoms of schizophrenia that would typically be addressed by the antipsychotic medication (haloperidol) itself. Tardive dyskinesia, a potential side effect of long-term antipsychotic use, would require discontinuation of the antipsychotic medication rather than administration of benztropine.

5. Which of the following situations might warrant a laboratory magnesium level?

• A. Hyperthyroidism
• B. Arthritis
• C. Ulcerative colitis
• D. Depression

Correct answer: C

Rationale: Ulcerative colitis can lead to symptoms such as abdominal pain, fever, diarrhea, and weight loss. This condition may impact the absorption of certain nutrients, including magnesium. Therefore, patients with chronic gastrointestinal conditions like ulcerative colitis should be screened for electrolyte imbalances related to impaired digestion. Hyperthyroidism, arthritis, and depression do not typically directly affect magnesium levels in the same way as gastrointestinal conditions like ulcerative colitis.

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