Nursing Elites

1. A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency department with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?

• A. Complaints of chest pain and shortness of breath
• B. Hypotension and venous pooling in the extremities
• C. Profuse diaphoresis and severe, pounding headache
• D. Pain and burning sensation upon urination and hematuria

Correct answer: C

Rationale: Autonomic dysreflexia is a life-threatening condition commonly seen in clients with spinal cord injuries above the T6 level. It is characterized by a sudden onset of excessively high blood pressure due to a noxious stimulus below the level of injury, often a distended bladder. The exaggerated sympathetic response leads to vasoconstriction, resulting in symptoms such as profuse diaphoresis (sweating) and a severe, pounding headache. These symptoms are the body's attempt to lower blood pressure. Complaints of chest pain and shortness of breath (Choice A) are not typical findings in autonomic dysreflexia. Hypotension and venous pooling (Choice B) are opposite manifestations of autonomic dysreflexia, which is characterized by hypertension. Pain and burning sensation upon urination and hematuria (Choice D) are indicative of a urinary tract infection and not specific to autonomic dysreflexia.

2. When giving a report about a client who had a gastrectomy from the intensive care unit to the post-surgical unit nurse, what is the most effective way to assure essential information is reported?

• A. Give the report face-to-face with both nurses in a quiet room.
• B. Audiotape the report for future reference and documentation.
• C. Use a printed checklist with information individualized for the client.
• D. Document essential transfer information in the client's electronic health record.

Correct answer: C

Rationale: Using a printed checklist with individualized information is the most effective way to ensure that all key details about the client who had a gastrectomy are covered during the report. This method helps in structuring the information systematically, reducing the risk of missing important details. Face-to-face communication in a quiet room (Choice A) is important for effective communication but may not guarantee the coverage of all essential information. Audiotaping the report (Choice B) may not be practical for immediate reference or interaction. Documenting in the electronic health record (Choice D) is essential but may not facilitate a comprehensive real-time exchange of information between the nurses.

3. A client is tested for HIV with the use of an enzyme-linked immunosorbent assay (ELISA), and the test result is positive. The nurse should tell the client that:

• A. HIV infection has been confirmed
• B. The client probably has an opportunistic infection
• C. The test will need to be confirmed with the use of a Western blot
• D. A positive test is a normal result and does not mean that the client is infected with HIV

Correct answer: C

Rationale: When an ELISA test for HIV is positive, it is essential to confirm the result with a Western blot. The Western blot is the confirmatory test for HIV. Choice A is incorrect because a positive ELISA test does not confirm HIV infection. Choice B is incorrect as it assumes a different diagnosis. Choice D is incorrect because a positive ELISA test does indicate potential HIV infection and requires confirmation.

4. A client who has undergone pleural biopsy is being monitored by a nurse. Which finding indicates a potential complication for the client?

• A. Warm, dry skin
• B. Mild pain at the biopsy site
• C. Complaints of shortness of breath
• D. Capillary refill time of less than 3 seconds

Correct answer: C

Rationale: Complaints of shortness of breath are a concerning finding post-pleural biopsy, as they may indicate a complication such as a pneumothorax or hemothorax. Shortness of breath can be a sign of respiratory distress that requires immediate attention. Warm, dry skin, mild pain at the biopsy site, and a capillary refill time of less than 3 seconds are not typically associated with immediate complications following a pleural biopsy. Warm, dry skin may be a normal finding, mild pain can be expected at the biopsy site, and a capillary refill time of less than 3 seconds is within normal limits.

5. A client is scheduled for an arteriogram. The nurse should explain to the client that the arteriogram will confirm the diagnosis of occlusive arterial disease by:

• A. Showing the location of the obstruction and the collateral circulation.
• B. Scanning the affected extremity and identifying the areas of volume changes.
• C. Using ultrasound to estimate the velocity changes in the blood vessels.
• D. Determining how long the client can walk.

Correct answer: A

Rationale: The correct answer is A: Showing the location of the obstruction and the collateral circulation. An arteriogram is a diagnostic procedure that involves injecting a contrast agent to visualize the blood vessels and identify the location of any obstructions. This helps confirm the diagnosis of occlusive arterial disease by showing where the blockage is located and how collateral circulation is compensating for the reduced blood flow. Choices B, C, and D are incorrect because scanning the extremity, estimating velocity changes with ultrasound, or determining walking distance are not the primary purposes of an arteriogram in diagnosing occlusive arterial disease.

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