Nursing Elites

1. Which endocrine disorder would the nurse assess for in the client who has a closed head injury with increased intracranial pressure?

• A. Pheochromocytoma
• B. Diabetes insipidus
• C. Hashimoto's disease
• D. Gynecomastia

Correct answer: B

Rationale: The correct answer is B, Diabetes insipidus. Diabetes insipidus can develop after a head injury due to damage to the hypothalamus or pituitary gland, leading to a deficiency in antidiuretic hormone (ADH). Pheochromocytoma (Choice A) is a tumor of the adrenal gland that causes excessive release of catecholamines, leading to hypertension. Hashimoto's disease (Choice C) is an autoimmune condition affecting the thyroid gland. Gynecomastia (Choice D) refers to the enlargement of breast tissue in males and is not directly related to a closed head injury with increased intracranial pressure.

2. A client is transferred from the emergency department to the locked psychiatric unit after attempting suicide by taking 200 acetaminophen (Tylenol) tablets. The client is now awake and alert but refuses to speak with the nurse. In this situation, the nurse’s first priority is to:

• A. Establish a rapport to foster trust
• B. Place the client in full restraints
• C. Try to communicate with the client in writing
• D. Ensure safety by initiating suicide precautions

Correct answer: D

Rationale: In this scenario, the nurse's highest priority should be to ensure the client's safety by initiating suicide precautions. Given the history of a suicide attempt by taking a large number of acetaminophen tablets, there is a high risk of further self-harm. Placing the client in full restraints without assessing the situation properly may escalate anxiety and hinder therapeutic communication. Trying to communicate with the client in writing could be an option but ensuring immediate safety takes precedence. Establishing rapport is essential for building trust and therapeutic relationship, but safety concerns must be addressed first in this critical situation.

3. Which of the following is a primary intervention for managing hyperphosphatemia?

• A. Increasing calcium intake
• B. Increasing phosphorus intake
• C. Decreasing calcium intake
• D. Administering phosphate binders

Correct answer: D

Rationale: The correct answer is D, administering phosphate binders. Phosphate binders are a primary intervention for managing hyperphosphatemia as they help by binding phosphorus in the gut, preventing its absorption. Increasing calcium intake (choice A) or phosphorus intake (choice B) would exacerbate hyperphosphatemia. Decreasing calcium intake (choice C) is not a primary intervention for managing high phosphorus levels.

4. The client diagnosed with acute vein thrombosis is receiving a continuous heparin drip, an intravenous anticoagulant. The health care provider orders warfarin (Coumadin), an oral anticoagulant. Which action should the nurse take?

• A. Discontinue the heparin drip prior to initiating the Coumadin
• B. Check the client’s INR prior to beginning Coumadin
• C. Clarify the order with the health care provider as soon as possible
• D. Administer the Coumadin along with the heparin drip as ordered

Correct answer: D

Rationale: The correct action for the nurse to take is to administer the Coumadin along with the heparin drip as ordered. Heparin and warfarin are often given together initially because warfarin takes a few days to become effective. Discontinuing the heparin drip prior to initiating Coumadin could leave the patient without anticoagulation coverage during the period when warfarin's effects are not yet established. Checking the client's INR prior to beginning Coumadin is important but not the immediate action to take when both medications are ordered together. Clarifying the order with the health care provider is unnecessary in this scenario as it is common practice to give heparin and warfarin concurrently in the transition period.

5. The nurse instructs a client 5 days after a lumbar laminectomy with spinal fusion about how to move from a supine position to standing at the left side of the bed with a walker. Which of the following directions by the nurse is BEST?

• A. Raise the head of the bed so you are sitting straight up, bend your knees, and swing your legs to the side and then to the floor
• B. Rock your body from side to side, going further each time until you build up enough momentum to be lying on your right side, and then raise your trunk toward your toes
• C. Reach over to the left side rail with your right hand, pull your body onto its side, bend your upper leg so the foot is on the bed, and push down to elevate your trunk
• D. Focus on using your arms, the left elbow as a pivot with the left hand grasping the mattress edge and the right hand pushing on the mattress above the elbow, then slide your legs over the side of the mattress

Correct answer: C

Rationale: The correct method described in option C helps maintain spinal alignment while moving from a lying to a standing position, which is crucial after a lumbar laminectomy with spinal fusion. This technique minimizes strain on the back and promotes safe movement. Choices A, B, and D involve movements that could potentially strain the back, increase the risk of injury, or compromise the spinal alignment, making them less optimal for the client recovering from such surgery.

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