Nursing Elites

1. A 60-year-old male client is admitted to the hospital with the complaint of right knee pain for the past week. His right knee and calf are warm and edematous. He has a history of diabetes and arthritis. Which neurological assessment action should the nurse perform for this client?

• A. Glasgow Coma Scale
• B. Assess pulses, paresthesia, and paralysis distal to the right knee
• C. Assess pulses, paresthesia, and paralysis proximal to the right knee
• D. Optic nerve using an ophthalmoscope

Correct answer: B

Rationale: In this scenario, the nurse should assess pulses, paresthesia, and paralysis distal to the right knee to evaluate for neurovascular compromise. This assessment helps determine the perfusion and sensation of the lower extremity, which is crucial in identifying potential vascular or nerve damage that may be causing the client's symptoms.

2. Why is a low-protein diet recommended for a client with hepatic encephalopathy?

• A. Hyperglycemia
• B. Hypoglycemia
• C. Increased ammonia levels
• D. Electrolyte imbalance

Correct answer: C

Rationale: A low-protein diet is recommended for clients with hepatic encephalopathy to reduce ammonia levels. Ammonia, a byproduct of protein metabolism, can accumulate in the blood due to impaired liver function. Elevated ammonia levels can lead to worsening hepatic encephalopathy, a condition characterized by cognitive and neurological disturbances. Therefore, by limiting protein intake, the production of ammonia is reduced, thereby helping to manage hepatic encephalopathy. Choices A, B, and D are incorrect because hepatic encephalopathy is not primarily related to hyperglycemia, hypoglycemia, or electrolyte imbalance. The focus is on reducing ammonia levels to improve the condition.

3. A client with a diagnosis of schizophrenia is being treated with risperidone (Risperdal). Which finding should the nurse report to the healthcare provider immediately?

• A. Weight gain.
• B. Dry mouth.
• C. Muscle rigidity.
• D. Drowsiness.

Correct answer: C

Rationale: Muscle rigidity is a crucial finding to report immediately as it can indicate neuroleptic malignant syndrome (NMS), a rare but potentially life-threatening reaction to antipsychotic medications. NMS is characterized by muscle rigidity, high fever, autonomic dysfunction, and altered mental status. Prompt recognition and intervention are essential to prevent serious complications or death.

4. What is the most likely diagnosis in a 30-year-old woman with right upper quadrant pain, fever, and jaundice, along with elevated white blood cell count and bilirubin levels?

• A. Acute hepatitis
• B. Acute cholecystitis
• C. Acute cholangitis
• D. Pancreatic cancer

Correct answer: C

Rationale: The combination of right upper quadrant pain, fever, jaundice, elevated white blood cell count, and bilirubin levels is classic for acute cholangitis, which is an infection of the bile ducts. Acute hepatitis typically presents with other liver function abnormalities, while acute cholecystitis is characterized by gallbladder inflammation. Pancreatic cancer would not typically present with these specific symptoms and lab findings.

5. When a client expresses, 'I don't know how I will go on' while discussing feelings related to a recent loss, the nurse remains silent. What is the most likely reason for the nurse's behavior?

• A. The nurse is indicating disapproval of the statement.
• B. The nurse is showing respect for the client's loss.
• C. Silence is mirroring the client's sadness.
• D. Silence enables the client to contemplate what was expressed.

Correct answer: D

Rationale: In therapeutic communication, silence can offer the client an opportunity to process their emotions and thoughts. By remaining silent, the nurse provides a space for the client to reflect on their own words, facilitating deeper exploration and understanding of their feelings.

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