Nursing Elites

1. A 59-year-old male client is brought to the emergency room where he is assessed to have a Glasgow Coma Scale of 3. Based on this assessment, how should the nurse characterize the client's condition?

• A. The client is experiencing increased intracranial pressure
• B. He has a good prognosis for recovery
• C. This client is conscious, but is not oriented to time and place
• D. He is in a coma, and has a very poor prognosis

Correct answer: D

Rationale: A Glasgow Coma Scale of 3 indicates severe neurological impairment, suggesting a deep coma or even impending death. This client's condition is critical, and he has a very poor prognosis. Choice A is incorrect because a GCS of 3 does not directly indicate increased intracranial pressure. Choice B is incorrect as a GCS of 3 signifies a grave neurological status. Choice C is incorrect as a GCS of 3 represents a state of unconsciousness rather than being conscious but disoriented.

2. A client who has a new prescription for warfarin (Coumadin) asks the nurse how the medication works. What explanation should the nurse provide?

• A. It dissolves blood clots
• B. It prevents the blood from clotting
• C. It thins the blood
• D. It decreases the risk of infection

Correct answer: B

Rationale: The correct answer is B: 'It prevents the blood from clotting.' Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors in the liver, thereby preventing the formation of blood clots. Choice A is incorrect because warfarin does not dissolve existing blood clots but prevents new ones from forming. Choice C is partially correct but not as specific as choice B in explaining how warfarin works. Choice D is unrelated to the mechanism of action of warfarin and is incorrect.

3. The nurse observes a client in a wheelchair with a vest restraint in place. What nursing intervention is most important for the nurse to implement?

• A. Assess the need for continued restraint
• B. Check the client for urinary incontinence
• C. Determine skin integrity under the vest
• D. Perform range-of-motion exercises on extremities

Correct answer: A

Rationale: The correct answer is to assess the need for continued restraint. This is the most important nursing intervention as it ensures the client's safety and autonomy. Checking for urinary incontinence (Choice B) may be important but is not the priority in this situation. Determining skin integrity under the vest (Choice C) is essential but not as crucial as assessing the need for continued restraint. Performing range-of-motion exercises (Choice D) is important for client mobility but not the priority when a restraint is in place.

4. The nurse offers diet teaching to a female college student who was diagnosed with iron-deficiency anemia following her voluntary adoption of a lacto-vegetarian diet. What nutrients should the nurse suggest this client eat to best meet her nutritional needs while allowing her to adhere to a lacto-vegetarian diet?

• A. Drink whole milk instead of skim milk to enhance the body's production of amino acids
• B. Take vitamin K 10mg PO daily to enhance production of red blood cells
• C. Increase amounts of dark yellow vegetables such as carrots to fortify iron stores
• D. Combine several legumes and grains such as beans and rice to form complete proteins

Correct answer: D

Rationale: Combining legumes and grains ensures the client receives all essential amino acids to form complete proteins, which is crucial in a vegetarian diet. Options A, B, and C are incorrect. Option A is not necessary as there are plant-based sources of essential amino acids in a lacto-vegetarian diet. Option B suggests vitamin K, which is not directly related to enhancing red blood cell production. Option C mentions increasing dark yellow vegetables, which are sources of non-heme iron, but combining legumes and grains is more effective in addressing the protein needs of a lacto-vegetarian.

5. While assessing a client who is experiencing Cheyne-Stokes respirations, the nurse observes periods of apnea. What action should the nurse implement?

• A. Elevate the head of the client's bed
• B. Auscultate the client's breath sounds
• C. Measure the length of the apneic periods
• D. Suction the client's oropharynx

Correct answer: C

Rationale: When a nurse observes periods of apnea in a client experiencing Cheyne-Stokes respirations, measuring the length of the apneic periods is essential. This action helps in determining the severity of Cheyne-Stokes respirations by providing valuable information about the duration of interrupted breathing cycles. Elevating the head of the client's bed (Choice A) may be beneficial in some respiratory conditions but is not the priority in Cheyne-Stokes respirations. Auscultating the client's breath sounds (Choice B) is a general assessment and may not directly address the issue of apnea in Cheyne-Stokes respirations. Suctioning the client's oropharynx (Choice D) is not the initial intervention for managing Cheyne-Stokes respirations unless secretions are obstructing the airway.

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