Nursing Elites

1. A 28-year-old male has a diagnosis of AIDS. The patient has had a two-year history of AIDS. The most likely cognitive deficits include which of the following?

• A. Disorientation
• B. Sensory changes
• C. Inability to produce sound
• D. Hearing deficits

Correct answer: A

Rationale: In individuals with AIDS, cognitive deficits commonly manifest as confusion and disorientation, making choice A, 'Disorientation,' the correct answer. Sensory changes (choice B) and hearing deficits (choice D) are more related to sensory processing rather than cognitive impairment. 'Inability to produce sound' (choice C) is more indicative of a speech or language deficit rather than a cognitive impairment typically seen in AIDS patients.

2. A client had a C5 spinal cord contusion that resulted in quadriplegia. Two days after the injury occurred, the nurse sees his mother crying in the waiting room. The mother asks the nurse whether her son will ever play football again. Which of the following is the best initial response?

• A. "Given time and motivation, your son may regain some function, but I will seek more information from the physician."?
• B. Maintain a calm demeanor and speech pattern while addressing the mother's concerns.
• C. "I'm not sure, but I'll call the physician to discuss this with you promptly."?
• D. "It's not beneficial for your son if you get upset."?

Correct answer: C

Rationale: The best initial response in this situation is to acknowledge the mother's concern, express uncertainty, and offer to obtain more information from the physician. By saying, "I'm not sure, but I'll call the physician to discuss this with you promptly,"? the nurse demonstrates empathy, honesty, and a commitment to providing accurate information. Offering vague reassurance (Choice A) may raise false hopes as outcomes for spinal cord injuries are unpredictable. While maintaining a calm demeanor (Choice B) is important, it does not directly address the mother's immediate need for information. Discouraging the mother from feeling upset (Choice D) is dismissive of her emotions and does not address her question, which is seeking information about her son's prognosis.

3. A client with a history of peptic ulcer disease arrives in the emergency department complaining of weakness and states that he vomited 'a lot of dark coffee-looking stomach contents.' The client is cool and moist to the touch. BP 90/50, HR 110, RR 20, T 98. Of the following physician orders, which will the nurse perform first?

• A. Initiate oxygen at 2 liters/nasal cannula.
• B. Start an IV of NS at 150 ml/hr
• C. Insert NG tube to low suction
• D. Attach the client to the ECG monitor

Correct answer: A

Rationale: The correct answer is to initiate oxygen at 2 liters/nasal cannula. The client is presenting signs of shock with hypotension, tachycardia, and cool, moist skin, which indicate poor tissue perfusion. Oxygen should be administered first to improve tissue oxygenation. While all interventions are important, oxygenation takes priority in the ABCs of emergency care. Starting an IV of NS, inserting an NG tube, and attaching the client to the ECG monitor are necessary interventions but should follow the priority of oxygen administration in this scenario.

4. A nurse is caring for a patient in the step-down unit. The patient has signs of increased intracranial pressure. Which of the following is not a sign of increased intracranial pressure?

• A. Bradycardia
• B. Increased pupil size bilaterally
• C. Change in LOC
• D. Vomiting

Correct answer: B

Rationale: The correct answer is 'Increased pupil size bilaterally.' When assessing for signs of increased intracranial pressure, bilateral pupil dilation is not typically associated with this condition. Instead, unilateral pupil changes, especially one pupil becoming dilated or non-reactive while the other remains normal, are indicative of increased ICP. Bradycardia, a change in level of consciousness (LOC), and vomiting are commonly seen in patients with increased intracranial pressure due to the brain's response to the rising pressure. Therefore, the presence of bilateral pupil dilation goes against the typical pattern observed in patients with increased intracranial pressure.

5. Which of the following is an inappropriate item to include in planning care for a severely neutropenic client?

• A. Transfuse neutrophils (granulocytes) to prevent infection.
• B. Exclude raw vegetables from the diet.
• C. Avoid administering rectal suppositories.
• D. Prohibit vases of fresh flowers and plants in the client's room.

Correct answer: A

Rationale: Transfusing neutrophils (granulocytes) to prevent infection is inappropriate in the care of a severely neutropenic client. Neutrophils normally comprise 70% of all white blood cells and can be beneficial in a selected population of infected, severely granulocytopenic clients (less than 500/mm3) who do not respond to antibiotic therapy and who are expected to experience prolonged suppression of granulocyte production. Therefore, transfusing neutrophils is not a standard practice in caring for neutropenic clients. The other choices are appropriate in caring for a severely neutropenic client: excluding raw vegetables from the diet to reduce the risk of infections from potential pathogens, avoiding administering rectal suppositories to prevent any injury or infection due to mucosal damage, and prohibiting vases of fresh flowers and plants in the client's room to minimize the risk of exposure to environmental pathogens.

Similar Questions