Nursing Elites

1. A client post-thyroidectomy is being monitored for signs of hypocalcemia. Which of the following symptoms should the nurse be most concerned about?

• A. Tingling in the hands and around the mouth.
• B. Nausea and vomiting.
• C. Constipation.
• D. Bradycardia.

Correct answer: A

Rationale: The correct answer is A: Tingling in the hands and around the mouth. This symptom is a classic sign of hypocalcemia, which can occur after thyroidectomy if the parathyroid glands were inadvertently damaged during surgery. Nausea and vomiting (Choice B) are not specific to hypocalcemia. Constipation (Choice C) is not a typical symptom of hypocalcemia. Bradycardia (Choice D) is more commonly associated with hypothyroidism rather than hypocalcemia.

2. A client who is post-operative from a bowel resection is experiencing abdominal distention and pain. The nurse notices the client has not passed gas or had a bowel movement. What should the nurse assess first?

• A. The client's bowel sounds.
• B. The client's fluid intake.
• C. The client's pain level.
• D. The client's surgical incision.

Correct answer: A

Rationale: Assessing bowel sounds is crucial in this situation as it helps determine if the client's gastrointestinal tract is functioning properly. Absent or hypoactive bowel sounds can indicate an ileus, a common post-operative complication. Assessing fluid intake (Choice B) is important but should come after assessing bowel sounds. Pain assessment (Choice C) is essential but addressing the physiological issue should take precedence. Checking the surgical incision (Choice D) is relevant but not the priority when the client is experiencing abdominal distention and potential gastrointestinal complications.

3. While assessing an older male client who takes psychotropic medications, the nurse observes uncontrollable hand movements and excessive blinking. Which information in the client's medical record should the nurse review?

• A. Prescription for lorazepam
• B. History of Parkinson's disease
• C. Screening for tardive dyskinesia
• D. Recent urine drug screen report

Correct answer: C

Rationale: The symptoms of uncontrollable hand movements and excessive blinking are indicative of tardive dyskinesia, a possible side effect of long-term use of psychotropic medications. Reviewing the screening for tardive dyskinesia is crucial to assess if these symptoms are related to the medication. Option A, the prescription for lorazepam, is less relevant as the focus should be on potential side effects rather than the specific medication. Option B, history of Parkinson's disease, is not directly related to the observed symptoms, which are more likely linked to medication side effects. Option D, recent urine drug screen report, is not as pertinent in this context compared to reviewing the screening for tardive dyskinesia.

4. The PN is reviewing care instructions with a client who has diabetic retinopathy and is experiencing glare around lights. What should the PN reinforce with the client?

• A. Cover eyes with moist, cool compresses to reduce glare
• B. Make adjustments to personal schedule to avoid driving at night
• C. Exert pressure on the inner canthus when tearing occurs
• D. Apply an eye shield at bedtime after instilling eye drops

Correct answer: B

Rationale: The correct answer is B. Avoiding driving at night is recommended for clients experiencing glare around lights due to diabetic retinopathy. This can help reduce the risk of accidents and visual discomfort. Making adjustments to the personal schedule to avoid nighttime driving is a practical approach to manage the glare. Choices A, C, and D are incorrect because covering eyes with compresses, exerting pressure on the inner canthus, or applying an eye shield are not effective strategies for managing glare associated with diabetic retinopathy.

5. The UAP reports to the PN that an assigned client experiences SOB when the bed is lowered for bathing. Which action should the PN implement?

• A. Obtain further data about the client's activity intolerance to position changes
• B. Advise the UAP to allow the client to rest before completing the bath
• C. Direct the UAP to obtain vital signs and a pulse oximetry reading
• D. Notify the healthcare provider about the client's episode of SOB

Correct answer: B

Rationale: Advising the UAP to allow the client to rest before completing the bath is the most appropriate action to take. This helps manage the shortness of breath (SOB) experienced by the client and prevents further stress. By giving the client time to rest, the PN ensures the client's comfort and safety during care activities. The other options are not the most immediate or appropriate actions in this scenario: obtaining further data about activity intolerance (choice A) may delay addressing the current issue, obtaining vital signs and pulse oximetry (choice C) is important but not as immediate as allowing the client to rest, and notifying the healthcare provider (choice D) is premature before trying a simple intervention like allowing the client to rest.

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