Nursing Elites

1. A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client's temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is:

• A. Maintain fluid and electrolyte balance
• B. Control nausea
• C. Manage pain
• D. Prevent urinary tract infection

Correct answer: C

Rationale: In the scenario presented, the priority nursing goal for a client with renal calculi experiencing moderate to severe flank pain and nausea should be to manage pain. Pain management is crucial as it alleviates suffering, improves comfort, and enhances the quality of life for the client. In the case of ureteral colic from renal calculi, the cornerstone of management is effective pain control. Prompt analgesia, typically achieved with parenteral narcotics or nonsteroidal anti-inflammatory drugs (NSAIDs), is essential to provide relief and facilitate the passage of the calculi. While maintaining fluid and electrolyte balance is important in clients with renal calculi, addressing pain takes precedence as it directly impacts the client's immediate well-being. Controlling nausea and preventing urinary tract infections are also important aspects of care, but they are secondary to managing the primary concern of pain in this urgent situation.

2. A client is admitted for a head injury. His body is lying in an abnormal position and the physician states he is exhibiting decorticate posturing. Based on this assessment, the nurse can expect to find the client with:

• A. The legs extended and rotated internally; the elbow, wrists, and fingers flexed
• B. The legs pulled toward the chest; the head bent back at a 30-degree angle
• C. The back arched; the arms and legs extended and rigid
• D. The legs extended and rotated externally; the head turned to the right or the left

Correct answer: A

Rationale: Decorticate posturing is indicative of an injury to the corticospinal tract, resulting in abnormal posturing. It may occur spontaneously or in response to stimulation. This posture involves the legs being extended and rotated internally, while the elbows, wrists, and fingers are flexed inward. Choice A is correct because it accurately describes the expected positioning associated with decorticate posturing. Choices B, C, and D are incorrect. Choice B describes a different type of posturing known as opisthotonos. Choice C describes an exaggerated arching of the back, which is not characteristic of decorticate posturing. Choice D describes a different type of posturing with external rotation of the legs and head turning to the side, not consistent with decorticate posturing.

3. Based on Mr. C's assessment, which of the following nursing interventions is most appropriate?

• A. Elevate the lower extremities to 45 degrees to promote venous return
• B. Place Mr. C in the Trendelenburg position
• C. Administer total parenteral nutrition
• D. Monitor urine output

Correct answer: D

Rationale: In the context of Mr. C's assessment, the most appropriate nursing intervention is to monitor urine output. A client in hypovolemic shock may experience decreased urine output due to poor kidney perfusion. By monitoring urine output, the nurse can assess renal function and fluid status. Administering total parenteral nutrition (Choice C) is not indicated based on the information provided, as the priority is to stabilize the client's condition. Elevating the lower extremities (Choice A) may be helpful in some cases but is not the priority in this situation. Placing Mr. C in the Trendelenburg position (Choice B) is contraindicated in hypovolemic shock as it can worsen venous return and compromise cardiac output.

4. The pediatric nurse caring for a 3-year-old child with cerebral palsy (CP) prepares a home care teaching plan for the caregivers on discharge. Which items will the nurse include in the teaching plan? (Select one that does not apply.)

• A. Apply splints and braces to facilitate muscle control.
• B. Buy toys that are appropriate for the child's abilities.
• C. Encourage the child to perform self-care tasks.
• D. Use skeletal muscle relaxants for short-term control.

Correct answer: D

Rationale: When developing a discharge teaching plan for a child with cerebral palsy (CP), the nurse should focus on strategies to enhance the child's independence and functional abilities. Choices A, B, and C are appropriate interventions to include in the teaching plan for a child with CP. Applying splints and braces can help facilitate muscle control and improve body functioning. Buying toys that are appropriate for the child's abilities can promote engagement and development. Encouraging the child to perform self-care tasks fosters independence and skill development. However, the use of skeletal muscle relaxants for short-term control is not typically a part of routine care for pediatric patients with CP. These medications are usually reserved for specific situations and are not a standard component of home care teaching plans for children with CP.

5. Your patient has shown the following signs and symptoms: Feeling very thirsty, large amount of water intake, dryness of the mouth, and urinary frequency. What physical disorder does this patient most likely have?

• A. Diabetes
• B. Angina
• C. Hypertension
• D. Hypotension

Correct answer: A

Rationale: The patient is exhibiting classic signs of diabetes, such as polydipsia (feeling very thirsty), polyuria (large amount of water intake and urinary frequency), and xerostomia (dryness of the mouth). These symptoms are indicative of high blood glucose levels, which are characteristic of diabetes. Other common signs of diabetes include poor vision, unexplained weight loss, peripheral neuropathy (tingling in the feet and hands), and fatigue. Angina is chest pain due to reduced blood flow to the heart, not associated with the symptoms described in the patient. Hypertension is high blood pressure, which typically does not present with these specific symptoms related to diabetes. Hypotension is low blood pressure and is not consistent with the signs and symptoms presented by the patient, pointing more towards diabetes as the likely diagnosis.

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