Nursing Elites

1. When assessing a client with a diagnosis of bipolar disorder who reports taking a handful of medications, what information is most important to obtain?

• A. What drugs the client used in the suicide attempt.
• B. When the client last took medications for bipolar disorder.
• C. Whether the client has attempted suicide before.
• D. Which family member has the suicide note.

Correct answer: A

Rationale: The correct answer is to obtain information on what drugs the client used in the suicide attempt. This information is crucial for assessing the severity of the overdose, potential drug interactions, and determining the appropriate treatment plan. Choice B is not as urgent as identifying the drugs taken during the suicide attempt. Choice C, while important, is not as immediately critical as knowing the specific medications involved. Choice D is unrelated to the immediate medical needs of the client.

2. An older client with chronic emphysema is admitted to the emergency room with acute weakness, palpitations, and vomiting. Which information is most important for the nurse to obtain during the initial interview?

• A. Recent compliance with prescribed medications.
• B. Sleep patterns during the previous few weeks.
• C. History of smoking over the past 6 months.
• D. Activity level prior to the onset of symptoms.

Correct answer: A

Rationale: The correct answer is A. In this scenario, the most critical information for the nurse to obtain during the initial interview is the recent compliance with prescribed medications. This is crucial to understand the client's baseline condition and management of chronic emphysema. Monitoring medication adherence can provide insights into potential exacerbating factors that may have led to the current acute symptoms. Choices B, C, and D are not as crucial in this situation. Sleep patterns, smoking history, and activity levels are important aspects of the client's overall health but do not take precedence over medication compliance when addressing acute symptoms in a client with chronic emphysema.

3. A client is receiving lactulose for signs of hepatic encephalopathy. To evaluate the therapeutic response, which assessment should the nurse obtain?

• 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. Lactulose is used to reduce ammonia levels in hepatic encephalopathy, which can affect brain function. Therefore, monitoring the client's level of consciousness is crucial to evaluate the therapeutic response. Changes in consciousness can indicate the effectiveness of lactulose in reducing ammonia levels. Choices A, B, and C are incorrect because while they are important assessments in various conditions, they are not specifically related to evaluating the therapeutic response of lactulose in hepatic encephalopathy.

4. A female client with acute respiratory distress syndrome (ARDS) is sedated and on a ventilator with 50% FIO2. What assessment finding warrants immediate intervention?

• A. Assess the client’s lung sounds bilaterally.
• B. Diminished left lower lobe sounds.
• C. Monitor ventilator settings for changes in oxygen levels.
• D. Increased sputum production and shortness of breath.

Correct answer: B

Rationale: Diminished breath sounds in a sedated client with ARDS and on a ventilator indicate collapsed alveoli, which requires immediate intervention, such as chest tube insertion, to prevent further lung damage. Assessing bilateral lung sounds (Choice A) is important but not as urgent as identifying diminished sounds in a specific location. Monitoring ventilator settings (Choice C) is essential but does not directly address the immediate need for intervention due to diminished breath sounds. Increased sputum production and shortness of breath (Choice D) may indicate other issues but are not specific to the urgency of addressing diminished breath sounds in ARDS.

5. A client with cirrhosis is admitted with jaundice, fatigue, and a distended abdomen. Which laboratory result is most important for the nurse to monitor?

• A. Ammonia level
• B. White blood cell count
• C. Albumin level
• D. Hemoglobin level

Correct answer: A

Rationale: Corrected Rationale: In clients with cirrhosis, elevated ammonia levels can lead to hepatic encephalopathy, which is a serious complication. Monitoring ammonia levels is crucial to assess for changes in mental status and initiate treatment if needed. White blood cell count (choice B) is not the most important parameter to monitor in this scenario as it does not directly relate to the complications of cirrhosis. Albumin level (choice C) and hemoglobin level (choice D) are also important in cirrhosis, but in this case, monitoring ammonia level takes precedence due to its direct association with hepatic encephalopathy.

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