Nursing Elites

1. Which finding indicates to the nurse that a patient's transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective?

• A. Increased serum albumin level
• B. Decreased indirect bilirubin level
• C. Improved alertness and orientation
• D. Fewer episodes of bleeding varices

Correct answer: D

Rationale: The correct answer is 'Fewer episodes of bleeding varices.' A transjugular intrahepatic portosystemic shunt (TIPS) is used to reduce pressure in the portal venous system, thus decreasing the risk of bleeding from esophageal varices. This outcome would indicate the effectiveness of the TIPS procedure. The other choices are incorrect because: Increased serum albumin level and decreased indirect bilirubin level are not direct indicators of TIPS effectiveness. Improved alertness and orientation could be influenced by various factors and may not directly correlate with the effectiveness of the TIPS procedure. Additionally, TIPS can actually increase the risk of hepatic encephalopathy, which contradicts the choice of improved alertness and orientation.

2. A client is seen for testing to rule out Rocky Mountain Spotted Fever. Which of the following signs or symptoms is associated with this condition?

• A. Fever and rash
• B. Circumoral cyanosis
• C. Elevated glucose levels
• D. All of the above

Correct answer: A

Rationale: The correct answer is 'Fever and rash.' Rocky Mountain Spotted Fever (RMSP) is caused by the R. rickettsii pathogen, which damages blood vessels. Patients with RMSP typically present with fever, edema, and a rash that initially appears on the hands and feet before spreading across the body. The disease manifests following a tick bite. Choice A is correct as fever and rash are key indicators of RMSP. Circumoral cyanosis (choice B) is not typically associated with RMSP; it refers to a bluish discoloration around the mouth and is more indicative of oxygen deprivation. Elevated glucose levels (choice C) are not specific signs of RMSP. Therefore, choice D, 'All of the above,' is incorrect since only choice A, 'Fever and rash,' is associated with Rocky Mountain Spotted Fever.

3. A patient with pneumonia has a fever of 101.4 F (38.6 C), a nonproductive cough, and an oxygen saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the highest priority?

• A. Hyperthermia related to infectious illness
• B. Impaired transfer ability related to weakness
• C. Ineffective airway clearance related to thick secretions
• D. Impaired gas exchange related to respiratory congestion

Correct answer: D

Rationale: The correct answer is 'Impaired gas exchange related to respiratory congestion.' While all the nursing diagnoses are relevant to the patient's condition, the priority should be given to impaired gas exchange due to the patient's low oxygen saturation level of 88%. This indicates a significant risk of hypoxia for all body tissues unless the gas exchange is improved. Addressing impaired gas exchange is crucial to ensure adequate oxygenation and prevent further complications. Hyperthermia, impaired transfer ability, and ineffective airway clearance are important concerns but addressing gas exchange takes precedence in this scenario.

4. A patient has taken an overdose of aspirin. Which of the following should a nurse closely monitor during acute management of this patient?

• A. Onset of pulmonary edema
• B. Metabolic alkalosis
• C. Respiratory alkalosis
• D. Parkinson's disease type symptoms

Correct answer: A

Rationale: The correct answer is to monitor the onset of pulmonary edema. In cases of aspirin overdose, metabolic acidosis is a common consequence that can lead to the development of pulmonary edema. Early signs of aspirin poisoning include symptoms like tinnitus, hyperventilation, vomiting, dehydration, and fever. Late signs may manifest as drowsiness, bizarre behavior, unsteady walking, and coma. Aspirin poisoning can cause abnormal breathing that is typically rapid and deep. Pulmonary edema may occur due to increased capillary permeability in the lungs, leading to the leakage of proteins and fluid transudation in renal and pulmonary tissues. Changes in renal tubule permeability can also affect colloid osmotic pressure, potentially contributing to pulmonary edema. Monitoring pulmonary edema is crucial in managing aspirin overdose cases to prevent further complications. Choices B, C, and D are incorrect because metabolic alkalosis, respiratory alkalosis, and Parkinson's disease type symptoms are not typically associated with aspirin overdose and are not primary concerns in its acute management.

5. A mother brings her 26-month-old to the well-child clinic. She expresses frustration and anger due to her child's constant saying 'no' and refusal to follow her directions. The nurse explains this is normal for his age, as negativism is attempting to meet which developmental need?

• A. Trust
• B. Initiative
• C. Independence
• D. Self-esteem

Correct answer: C

Rationale: In Erikson's theory of development, toddlers struggle to assert independence. They often use the word 'no' even when they mean yes. This stage is called autonomy versus shame and doubt. The child's behavior of saying 'no' and resisting directions reflects the developmental need for independence, not trust (option A), initiative (option B), or self-esteem (option D). Trust is typically associated with early infancy, initiative with preschool age, and self-esteem with later childhood and adolescence.

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