Nursing Elites

1. A client with a history of seizures is receiving phenytoin (Dilantin). The nurse should monitor the client for which of the following side effects?

• A. Hypertension
• B. Hyperglycemia
• C. Gingival hyperplasia
• D. Hypokalemia

Correct answer: C

Rationale: The correct answer is C: Gingival hyperplasia. Phenytoin can cause gingival hyperplasia, characterized by an overgrowth of gum tissue. It is important for the nurse to monitor the client for this side effect as it can lead to oral health issues. Choices A, B, and D are incorrect. Phenytoin does not typically cause hypertension, hyperglycemia, or hypokalemia as common side effects.

2. As a community health nurse engaged in the process of community empowerment, which action is essential for you to take?

• A. Gathering data from the community
• B. Making decisions for people in the community
• C. Forming partnerships with people in the community
• D. Accepting responsibility for people’s actions

Correct answer: C

Rationale: In the process of community empowerment, forming partnerships with people in the community is essential. This fosters collaboration, engagement, and shared decision-making, enabling the community to identify its needs, resources, and priorities. Gathering data from the community (Choice A) is important for understanding the community's health status but forming partnerships goes beyond data collection by actively involving community members in decision-making. Making decisions for people in the community (Choice B) undermines empowerment as it takes away their autonomy and control. Accepting responsibility for people’s actions (Choice D) is not synonymous with empowerment and can lead to disempowerment by creating dependency rather than fostering self-reliance and self-determination.

3. A client with acute pancreatitis is experiencing severe abdominal pain. The nurse should implement which of the following interventions?

• A. Encourage oral intake
• B. Administer opioid analgesics
• C. Apply a heating pad to the abdomen
• D. Place the client in a supine position

Correct answer: B

Rationale: The correct intervention for a client with acute pancreatitis experiencing severe abdominal pain is to administer opioid analgesics. Opioids are effective in managing the severe pain associated with acute pancreatitis. Encouraging oral intake may exacerbate the symptoms and is contraindicated due to the need for bowel rest. Applying a heating pad to the abdomen can worsen inflammation and should be avoided. Placing the client in a supine position may not provide relief and could potentially lead to increased discomfort.

4. A client asks the nurse about including her 2 and 12-year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?

• A. Focus on your sons' needs during the first days at home.
• B. Tell each child what he can do to help with the baby.
• C. Suggest that your husband spend more time with the boys.
• D. Ask the children what they would like to do for the newborn.

Correct answer: A

Rationale: The correct answer is A. Focusing on the older children's needs during the initial days at home is crucial as it helps them feel secure and valued during the transition. This approach allows the children to adjust to the new family dynamics and feel included in the care of their newborn sister. Choice B is incorrect as it focuses on tasks rather than addressing the children's emotional needs. Choice C is not the initial step and does not involve directly addressing the children's needs. Choice D puts the decision-making burden on the children rather than providing guidance and support.

5. The nurse is assigned to a newly delivered woman with HIV/AIDS. The student asks the nurse about how it is determined that a person has AIDS other than a positive HIV test. The nurse responds:

• A. The complaints of at least 3 common findings.
• B. The absence of any opportunistic infection.
• C. CD4 lymphocyte count is less than 200.
• D. Developmental delays in children.

Correct answer: C

Rationale: The correct answer is C. A CD4 count less than 200 cells/mm³ is a diagnostic criterion for AIDS. Choices A, B, and D are incorrect. Choice A is vague and does not reflect the diagnostic criteria for AIDS. Choice B is not accurate, as the presence of opportunistic infections, not their absence, is indicative of AIDS. Choice D is unrelated to the diagnosis of AIDS in adults.

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