Nursing Elites

1. A client receiving lactulose for hepatic encephalopathy needs evaluation. Which assessment should the nurse prioritize?

• 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. When managing hepatic encephalopathy with lactulose, monitoring the client's level of consciousness is crucial as it is a key indicator of the therapeutic response to lactulose in reducing ammonia levels. Changes in consciousness can reflect the effectiveness of treatment and the progression of hepatic encephalopathy. Option A, percussion of the abdomen, is not directly related to evaluating the response to lactulose. Option B, blood glucose level, is important but not the priority in this context. Option C, serum electrolytes, while significant in liver disease, do not directly assess the impact of lactulose therapy on hepatic encephalopathy.

2. The healthcare provider prescribes a sepsis protocol for a client with multi-organ failure caused by a ruptured appendix. Which intervention is most important for the nurse to include in the care plan?

• A. Ensure early ambulation
• B. Administer antibiotics as prescribed
• C. Maintain strict intake and output
• D. Monitor blood glucose levels

Correct answer: C

Rationale: In sepsis with multi-organ failure, monitoring intake and output is critical to assess renal function and fluid balance, as organ failure can cause fluid shifts and decreased kidney function. Antibiotics are essential to treat the infection, but monitoring intake and output provides real-time insight into the client's status, helping to detect early signs of worsening organ function. Early ambulation and blood glucose monitoring are important aspects of care but are not as crucial as maintaining strict intake and output in this situation.

3. A woman who is breastfeeding calls her obstetrician’s office and reports increased anxiety since the vaginal delivery of her son three weeks ago. She stopped taking her antianxiety medications but is thinking of restarting them. What response should the nurse provide?

• A. Describe the potential transmission of drugs to the infant through breast milk.
• B. Encourage her to utilize stress-relieving alternatives, such as deep breathing.
• C. Explain that anxiety is a common reaction for mothers of 3-week-old infants.
• D. Inform her that some antianxiety medications are safe to take while breastfeeding.

Correct answer: D

Rationale: The correct answer is D because some antianxiety medications are considered safe during breastfeeding. The nurse should reassure the client and encourage her to discuss options with her healthcare provider to manage anxiety safely while continuing to breastfeed. Choice A is incorrect because it focuses on the transmission of drugs rather than providing guidance on safe medication use. Choice B, while promoting stress-relieving techniques, does not address the potential need for medication. Choice C is incorrect as it minimizes the woman's reported anxiety, which may require professional intervention.

4. During a neurologic assessment of a client with a suspected stroke, which finding is most concerning?

• A. Unilateral facial droop
• B. Slurred speech
• C. Weakness in one arm
• D. Sudden loss of consciousness

Correct answer: D

Rationale: Sudden loss of consciousness in a client with a suspected stroke is the most concerning finding as it indicates a more severe neurological event, such as brain stem involvement or hemorrhage, requiring immediate intervention. While unilateral facial droop, slurred speech, and weakness in one arm are all common signs of a stroke, sudden loss of consciousness signifies a critical condition that needs urgent attention and evaluation to prevent further complications.

5. A client with hypothyroidism is prescribed levothyroxine. What symptom indicates that the dosage may need adjustment?

• A. Increased appetite and weight gain.
• B. Increased sensitivity to cold and dry skin.
• C. Increased heart palpitations and sweating.
• D. Increased shortness of breath and rapid heart rate.

Correct answer: B

Rationale: Increased sensitivity to cold and dry skin may indicate that the dosage of levothyroxine is too low, requiring adjustment. This symptom is typical of hypothyroidism when the body's metabolism slows down, leading to feeling cold and having dry skin. Choices A, C, and D present symptoms more commonly associated with hyperthyroidism, where the body is in a state of overactivity, leading to weight loss, increased heart rate, and sweating. Therefore, these symptoms would not indicate the need for dosage adjustment in a client with hypothyroidism.

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