Nursing Elites

1. A client is suspected of being poisoned and presents with symmetric, descending flaccid paralysis, blurred vision, double vision, and dry mouth. The nurse should consider these findings consistent with which potential bioterrorism agent?

• A. ricin
• B. botulism toxin
• C. sulfur mustard
• D. yersinia pestis

Correct answer: B

Rationale: The correct answer is B: botulism toxin. Botulism toxin is associated with symmetric, descending flaccid paralysis, blurred vision, double vision, and dry mouth, which are consistent with the client's presentation. Ricin (Choice A) typically presents with gastrointestinal symptoms. Sulfur mustard (Choice C) is a blistering agent causing skin, eye, and respiratory issues. Yersinia pestis (Choice D) is associated with the bubonic plague, presenting with fever, malaise, and buboes.

2. The nurse is teaching childbirth preparation classes. One woman asks about her rights to develop a birthing plan. Which response made by the nurse would be best?

• A. "What is your reason for wanting such a plan?"
• B. "Have you talked with your health care provider about this?"
• C. "Let us discuss your rights as a couple."
• D. "Write your ideal plan for the next class."

Correct answer: C

Rationale: Discussing the rights as a couple allows for open communication and helps ensure that the birthing plan aligns with the couple's preferences and medical advice.

3. A client with multiple sclerosis is receiving baclofen (Lioresal). The nurse should monitor the client for which of the following side effects?

• A. Hypertension
• B. Muscle spasms
• C. Drowsiness
• D. Tachycardia

Correct answer: C

Rationale: The correct answer is C: Drowsiness. Baclofen, a muscle relaxant commonly used to treat conditions like multiple sclerosis, can cause drowsiness as a side effect. Monitoring for drowsiness is important to ensure the client's safety and well-being. Choice A, Hypertension, is incorrect because baclofen is not known to cause hypertension. Choice B, Muscle spasms, is not a common side effect of baclofen but rather the symptom it is used to treat. Choice D, Tachycardia, is also incorrect as baclofen is not associated with causing an increase in heart rate.

4. The nurse is performing a physical assessment on a client with insulin-dependent diabetes mellitus. Which client complaint calls for immediate nursing action?

• A. Diaphoresis and shakiness
• B. Reduced sensation in the lower leg
• C. Intense thirst and hunger
• D. Painful hematoma on thigh

Correct answer: A

Rationale: Diaphoresis and shakiness are classic signs of hypoglycemia in a client with insulin-dependent diabetes mellitus. Hypoglycemia is a medical emergency that requires immediate intervention to prevent further complications. The nurse should address this complaint promptly by providing a fast-acting source of glucose to raise the client's blood sugar levels. Reduced sensation in the lower leg may indicate peripheral neuropathy, which is a common complication of diabetes but does not require immediate action unless there are signs of injury. Intense thirst and hunger are symptoms of hyperglycemia, which also requires intervention but not as urgently as hypoglycemia. A painful hematoma on the thigh may require assessment and management, but it is not as urgent as addressing hypoglycemia.

5. Which of the following statements about breastfeeding is correct?

• A. Breastfeeding within 30 minutes after birth can stimulate breastmilk production
• B. Breastmilk should be started 24 hours after delivery
• C. Breastmilk given exclusively for the first 4 to 6 months of life helps avoid introduction of infection
• D. Breastfeeding should be done as often as the baby wants

Correct answer: C

Rationale: The correct statement about breastfeeding is that breastmilk given exclusively for the first 4 to 6 months of life helps avoid the introduction of infection. This practice is recommended by health experts for optimal infant health. Choice A is incorrect because breastfeeding should ideally start within the first hour after birth to stimulate breastmilk production. Choice B is incorrect because breastmilk should be initiated as soon as possible after delivery, not after 24 hours. Choice D is incorrect because while feeding on demand is generally encouraged, it should also follow a schedule to ensure adequate nutrition and growth for the baby.

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