Nursing Elites

1. A client complaining of chest pain is prescribed an intravenous infusion of nitroglycerin (Nitro-Bid). After the infusion is initiated, the occurrence of which symptom warrants the nurse discontinuing an intravenous infusion of nitroglycerin?

• A. Frontal headache
• B. Orthostatic hypotension
• C. Decrease in intensity of chest pain
• D. Cool clammy skin

Correct answer: D

Rationale: The correct answer is 'Cool clammy skin.' This assessment finding indicates decreased cardiac output that could result from excessive vasodilation. Cool clammy skin is a sign of poor perfusion, suggesting that the blood pressure might be dropping too low. Discontinuing the nitroglycerin infusion is crucial to prevent further complications. Choice A, 'Frontal headache,' is a common side effect of nitroglycerin but not a reason to discontinue the infusion unless severe or persistent. Choice B, 'Orthostatic hypotension,' may occur as a side effect of nitroglycerin but does not necessarily warrant discontinuation unless severe. Choice C, 'Decrease in intensity of chest pain,' is actually an expected therapeutic response to nitroglycerin and indicates improved myocardial perfusion, so it is not a reason to stop the infusion.

2. With a breech presentation, the nurse must be particularly alert for which of the following?

• A. quickening
• B. ophthalmia neonatorum
• C. pica
• D. prolapsed umbilical cord

Correct answer: D

Rationale: With a breech presentation, the nurse must be particularly alert for a prolapsed umbilical cord. Prolapsed umbilical cord is a critical emergency situation where the umbilical cord descends into the vagina before the fetal presenting part, leading to compression between the presenting part and the maternal pelvis. This compression can compromise or completely cut off fetoplacental perfusion, endangering the fetus. Immediate delivery should be attempted to save the fetus. Quickening refers to fetal movements felt by the mother, ophthalmia neonatorum is an eye infection in newborns, and pica is a condition characterized by cravings for non-nutritive substances, none of which are directly related to the risks associated with a breech presentation and prolapsed umbilical cord.

3. Which of the following blood pressure parameters indicates PIH? Elevation over a baseline of:

• A. 30 mmHg systolic and/or 15 mmHg diastolic.
• B. 40 mmHg systolic and/or 20 mmHg diastolic.
• C. 10 mmHg systolic and/or 5 mmHg diastolic.
• D. 20 mmHg systolic and/or 20 mmHg diastolic.

Correct answer: A

Rationale: The correct answer is A: 30 mmHg systolic and/or 15 mmHg diastolic. These parameters indicate mild PIH (pregnancy-induced hypertension). Mild preeclampsia is characterized by an increase in systolic blood pressure greater than 30 mmHg or an increase in diastolic blood pressure greater than 15 mmHg, observed on two readings taken 6 hours apart (or reaching 140/90). Choice B (40 mmHg systolic and/or 20 mmHg diastolic) represents a more significant elevation and would indicate a more severe condition than mild PIH. Choices C (10 mmHg systolic and/or 5 mmHg diastolic) and D (20 mmHg systolic and/or 20 mmHg diastolic) do not meet the criteria for indicating PIH as they are below the accepted parameters for mild PIH.

4. A client with stress incontinence should be advised:

• A. to avoid relying solely on absorbent undergarments.
• B. that Kegel exercises might help.
• C. that effective surgical treatments are available.
• D. that behavioral therapy can be beneficial.

Correct answer: B

Rationale: Kegel exercises, which involve tightening and releasing the pelvic floor muscles, can be beneficial for stress incontinence by strengthening the muscles that control urination. Choice A is incorrect as it is important for the client to know that absorbent undergarments can be used as a temporary solution but do not address the underlying issue. Choice C is incorrect as while surgical treatments are available, they are usually considered when conservative treatments like exercises and behavioral therapy have not been successful. Choice D is incorrect as behavioral therapy can be beneficial in managing stress incontinence through lifestyle and dietary modifications, bladder training, and more, contrary to the statement that it is ineffective.

5. Paula is a 32-year-old woman seeking evaluation and treatment for major depressive symptoms. A major nursing priority during the assessment process includes which of the following?

• A. meaning of current stressors
• B. possibility of self-harm
• C. motivation to participate in treatment
• D. presence of alcohol or other drug use

Correct answer: B

Rationale: The correct answer is to consider the possibility of self-harm during the assessment process. This is crucial because unless the client is first assessed for self-harm or suicide potential, the necessary degree of vigilance in the client's environment may not be observed. While understanding the meaning of current stressors is important for treatment planning, ensuring the client's safety takes precedence. Motivation to participate in treatment and the presence of alcohol or other drug use are also important aspects to assess but ensuring the client's safety is the top priority in this scenario.

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