Nursing Elites

1. A client who is at full-term gestation is in active labor and complains of a cramp in her leg. Which intervention should the nurse implement?

• A. Massage the calf and foot
• B. Elevate the leg above the heart
• C. Check the pedal pulse in the affected leg
• D. Extend the leg and flex the foot

Correct answer: D

Rationale: The correct intervention for a client in active labor complaining of a leg cramp is to extend the leg and flex the foot. This action helps stretch the muscles that are cramping, providing relief. Massaging the calf and foot (Choice A) may not be as effective for relieving the cramp. Elevating the leg above the heart (Choice B) is not indicated for a leg cramp. Checking the pedal pulse in the affected leg (Choice C) is unrelated to addressing the leg cramp.

2. The PN notes that an older female client has developed a nonproductive cough and seems more confused than the previous day. Vital signs are temperature 99.8°F, pulse 94, respirations 22, and B/P 108/54. Which intervention is most important for the PN to implement?

• A. Report the findings to the charge nurse
• B. Monitor the client's temperature hourly
• C. Offer the client fluids frequently
• D. Provide care to moisten oral mucosa

Correct answer: A

Rationale: The change in the client’s condition, especially confusion and a new cough, may indicate the onset of an infection such as pneumonia, which requires immediate attention. Reporting to the charge nurse ensures prompt evaluation and intervention. Monitoring the client's temperature hourly (Choice B) could be important but not the most critical at this point. Offering the client fluids frequently (Choice C) and providing care to moisten oral mucosa (Choice D) are not the priority interventions when facing potential signs of infection and confusion in the client.

3. The PN is caring for a client with schizophrenia who continues to repeat the last words heard. Which nursing problem should the PN document in the medical record?

• A. Altered thought processes
• B. Impaired social interaction
• C. Risk for self-directed violence
• D. Disturbed thought processes

Correct answer: D

Rationale: The correct answer is D: Disturbed thought processes. Echolalia, the repetition of heard words, is associated with disturbed thought processes, which are commonly seen in schizophrenia. Altered thought processes (Choice A) is a generic term and does not specifically address the behavior of repeating words. Impaired social interaction (Choice B) is not the primary concern when a client repeats the last words heard. Risk for self-directed violence (Choice C) is not directly related to the behavior of repeating words but focuses on the potential harm the client may cause to themselves.

4. What is the primary cause of diabetic ketoacidosis (DKA)?

• A. Insulin deficiency
• B. Overhydration
• C. Excess carbohydrate intake
• D. Excess insulin

Correct answer: A

Rationale: The correct answer is A: Insulin deficiency. Diabetic ketoacidosis occurs due to a severe lack of insulin, causing the body to break down fat for energy, leading to the production of ketones and acidification of the blood. Option B, Overhydration, is incorrect as DKA is characterized by dehydration rather than overhydration. Option C, Excess carbohydrate intake, is incorrect because while high blood sugar levels can contribute to DKA, the primary cause is insulin deficiency. Option D, Excess insulin, is also incorrect as DKA is not caused by an excess of insulin but rather by a lack of it.

5. A client has a prescription for a transcutaneous electrical nerve stimulator (TENS) unit for pain management during the postoperative period following a lumbar laminectomy. Which information should the nurse reinforce about the action of this adjuvant pain modality?

• A. The discharge of electricity will distract the client's focus from the pain
• B. An infusion of medication in the spinal canal will block pain perception
• C. Pain perception in the cerebral cortex is dulled by the unit's discharge of an electrical stimulus
• D. A mild electrical stimulus on the skin surface closes the gates of nerve conduction for severe pain

Correct answer: D

Rationale: The correct answer is D. TENS works by delivering a mild electrical stimulus to the skin, which can help close the 'gates' in the nervous system to block pain signals from reaching the brain, thus reducing pain perception. Choice A is incorrect because TENS does not distract from pain but rather helps manage it. Choice B is incorrect as it describes a different pain management technique involving medication in the spinal canal. Choice C is incorrect because TENS acts peripherally on nerve conduction rather than dulling pain perception in the cerebral cortex.

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