Nursing Elites

1. A client is admitted to the emergency department after a motor vehicle accident. The client has a Glasgow Coma Scale (GCS) score of 10. What does this score indicate?

• A. Mild impairment
• B. Moderate impairment
• C. Severe impairment
• D. Normal

Correct answer: B

Rationale: A Glasgow Coma Scale score of 10 falls into the range of moderate impairment, indicating the need for further assessment and monitoring. A GCS score of 10 suggests that the client is moderately impaired neurologically. Choices A, C, and D are incorrect because a GCS score of 10 does not indicate mild impairment, severe impairment, or normal neurological status, respectively.

2. A client with acute pancreatitis is receiving intravenous fluids and pain medication. What is the priority assessment for this client?

• A. Monitor bowel sounds
• B. Measure urine output
• C. Assess for abdominal tenderness
• D. Monitor blood glucose levels

Correct answer: D

Rationale: The correct answer is D: Monitor blood glucose levels. Clients with acute pancreatitis are prone to hyperglycemia due to impaired insulin production. Monitoring blood glucose levels is crucial to prevent complications like diabetic ketoacidosis. While assessing bowel sounds, urine output, and abdominal tenderness are important in the overall care of a client with acute pancreatitis, monitoring blood glucose levels takes priority to address the immediate risk of hyperglycemia.

3. A client with diabetes insipidus is admitted due to a pituitary tumor. What complication should the nurse monitor closely?

• A. Monitor for elevated blood pressure.
• B. Monitor for ketonuria.
• C. Monitor for peripheral edema.
• D. Monitor for hypokalemia.

Correct answer: D

Rationale: The correct answer is to monitor for hypokalemia. In diabetes insipidus, excessive urination can lead to electrolyte imbalances, particularly low potassium levels (hypokalemia). The loss of potassium through increased urination can result in muscle weakness, cardiac dysrhythmias, and other serious complications. Elevated blood pressure (Choice A) is not a typical complication of diabetes insipidus due to pituitary tumors. Ketonuria (Choice B) is more commonly associated with diabetes mellitus due to inadequate insulin levels. Peripheral edema (Choice C) is not a direct complication of diabetes insipidus.

4. A client is receiving lactulose for signs of hepatic encephalopathy. To evaluate the therapeutic response, which assessment should the nurse obtain?

• A. Percussion of the abdomen.
• B. Blood glucose level.
• C. Serum electrolytes.
• D. Level of consciousness.

Correct answer: D

Rationale: The correct answer is D: Level of consciousness. Lactulose is used to reduce ammonia levels in hepatic encephalopathy, which can affect brain function. Therefore, monitoring the client's level of consciousness is crucial to evaluate the therapeutic response. Changes in consciousness can indicate the effectiveness of lactulose in reducing ammonia levels. Choices A, B, and C are incorrect because while they are important assessments in various conditions, they are not specifically related to evaluating the therapeutic response of lactulose in hepatic encephalopathy.

5. After a thyroidectomy, which vital sign is the most important for the nurse to monitor closely?

• A. Monitor respiratory rate and rhythm.
• B. Assess for signs of hypocalcemia.
• C. Monitor for elevated body temperature.
• D. Check blood pressure every 30 minutes.

Correct answer: B

Rationale: The correct answer is B: Assess for signs of hypocalcemia. After a thyroidectomy, monitoring for hypocalcemia is crucial because damage to the parathyroid glands during surgery can result in low calcium levels, which may cause life-threatening complications. Monitoring respiratory rate and rhythm (choice A) is important but not the most critical in this situation. Monitoring for elevated body temperature (choice C) is less of a priority post-thyroidectomy. Checking blood pressure every 30 minutes (choice D) is not as vital as monitoring for hypocalcemia in this context.

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