Nursing Elites

1. A client who sustained a pellet gun injury with a resulting comminuted skull fracture is admitted overnight for observation. Which assessment finding obtained two hours after admission necessitates immediate intervention?

• A. The client complains of a throbbing headache rated 10 (on a scale of 1 to 10)
• B. The client repeatedly falls asleep while talking with the nurse
• C. The entry site has a slow trickle of bright red blood
• D. The entry site appears reddened and edematous

Correct answer: B

Rationale: In a client with a pellet gun injury and a comminuted skull fracture, repeatedly falling asleep while talking with the nurse is a concerning sign. It can indicate increased intracranial pressure or a deteriorating condition, requiring immediate intervention. The other options, such as a throbbing headache (choice A), slow trickle of bright red blood at the entry site (choice C), or reddened and edematous entry site (choice D), while important to monitor, do not directly indicate a need for immediate intervention as much as the client falling asleep repeatedly while talking does.

2. A client is admitted to a medical unit with the diagnosis of gastritis and chronic heavy alcohol abuse. What should the nurse administer to prevent the development of Wernicke's syndrome?

• A. Lorazepam (Ativan)
• B. Famotidine (Pepcid)
• C. Thiamine (Vitamin B1)
• D. Atenolol (Tenormin)

Correct answer: C

Rationale: Thiamine supplementation is critical in preventing Wernicke's syndrome, especially in clients with chronic alcohol use. Wernicke's syndrome is a neurological disorder caused by thiamine deficiency. Lorazepam is a benzodiazepine used for anxiety and not for preventing Wernicke's syndrome. Famotidine is an H2 blocker used to reduce stomach acid production but does not prevent Wernicke's syndrome. Atenolol is a beta-blocker used for hypertension and angina, not for preventing Wernicke's syndrome.

3. A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After stopping the medication abruptly, the client reports feeling very tired. Which nursing intervention is most important for the nurse to implement?

• A. Measure vital signs
• B. Auscultate breath sounds
• C. Palpate the abdomen
• D. Observe the skin for bruising

Correct answer: A

Rationale: Discontinuing prednisone abruptly can lead to adrenal insufficiency, which may result in symptoms such as fatigue. Monitoring vital signs is crucial in this situation to assess for potential complications like hypotension, which can be a sign of adrenal insufficiency. Auscultating breath sounds (choice B) is important but not the priority when considering the risk of adrenal insufficiency. Palpating the abdomen (choice C) and observing the skin for bruising (choice D) are not directly related to the potential complications of abruptly stopping prednisone.

4. What instruction should the nurse provide a pregnant client experiencing heartburn?

• A. Limit fluid intake between meals to prevent stomach over-distension
• B. Take an antacid at bedtime and when symptoms worsen
• C. Maintain an upright position for two hours after eating
• D. Eat small meals throughout the day to avoid a full stomach

Correct answer: D

Rationale: The correct answer is D: 'Eat small meals throughout the day to avoid a full stomach.' Heartburn is common in pregnancy due to increased intra-abdominal pressure and hormonal changes. Consuming small, frequent meals prevents the stomach from becoming overly full, reducing the likelihood of acid reflux and heartburn. Choice A is incorrect because limiting fluid intake between meals may not significantly impact heartburn. Choice B is not ideal as antacids should be taken as directed by a healthcare provider, not just at bedtime or when symptoms worsen. Choice C is less effective advice, as maintaining an upright position after eating may not directly address the root cause of heartburn.

5. The client with a mechanical valve replacement understands the discharge teaching when the client makes which statement?

• A. ''I will need to take antibiotics before any type of invasive dental work''
• B. ''I will not have to take any more heart medication since I have a new valve''
• C. ''I will need to have this valve replaced in about 10 years''
• D. ''I should notify my healthcare provider if I hear a clicking sound near my heart''

Correct answer: A

Rationale: The correct answer is A. Clients with mechanical valve replacements need to take prophylactic antibiotics before dental procedures to prevent endocarditis. Choice B is incorrect because even with a new valve, heart medications may still be necessary to manage the condition. Choice C is incorrect because mechanical valves typically do not need replacement as frequently as within 10 years. Choice D is incorrect because hearing a clicking sound near the heart could indicate valve malfunction, not just the need to notify the healthcare provider.

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