Nursing Elites

1. A client with cirrhosis is admitted with hepatic encephalopathy. Which clinical finding is most concerning?

• A. Confusion and altered mental status
• B. Increased abdominal girth
• C. Yellowing of the skin
• D. Peripheral edema

Correct answer: A

Rationale: Confusion and altered mental status are the most concerning clinical findings in a client with hepatic encephalopathy. These symptoms indicate worsening liver function and potential neurological complications, requiring immediate medical attention. Increased abdominal girth may suggest ascites, yellowing of the skin can indicate jaundice, and peripheral edema may be related to fluid retention, but in the context of hepatic encephalopathy, confusion and altered mental status take precedence due to the risk of rapid deterioration and the need for prompt management.

2. A female client with breast cancer who completed her first chemotherapy treatment today at an outpatient center is preparing for discharge. Which behavior indicates that the client understands her care needs?

• A. Rented movies and borrowed books to use while passing time at home
• B. Made an appointment with the oncologist for follow-up treatment
• C. Expressed concern about hair loss and fatigue
• D. Asked for dietary recommendations to manage nausea

Correct answer: A

Rationale: Choice A is the correct answer. Renting movies and borrowing books to use at home indicate that the client understands the need for rest and self-care after chemotherapy. This behavior demonstrates the client's intention to engage in activities that promote relaxation and recovery. Choices B, C, and D are incorrect because making an appointment for follow-up treatment, expressing concern about side effects like hair loss and fatigue, and asking for dietary recommendations are important but do not directly reflect the client's understanding of her immediate care needs post-chemotherapy.

3. Which assessment is most important for the nurse to include in the daily plan of care for a client with a burned extremity?

• A. Distal pulse intensity
• B. Skin integrity
• C. Pain levels
• D. Range of motion

Correct answer: A

Rationale: The correct answer is A: Distal pulse intensity. Monitoring distal pulses is crucial to ensure that circulation to the extremity is not compromised. This assessment helps in detecting any signs of decreased circulation, which is vital in managing a burned extremity. While skin integrity (choice B), pain levels (choice C), and range of motion (choice D) are also important assessments, monitoring distal pulse intensity takes precedence as it directly reflects the perfusion status of the affected extremity in a burned client.

4. A client with cirrhosis is admitted with ascites and jaundice. Which clinical finding is most concerning?

• A. Peripheral edema
• B. Increased abdominal girth
• C. Confusion and altered mental status
• D. Yellowing of the skin

Correct answer: C

Rationale: The correct answer is C. Confusion and altered mental status are the most concerning clinical findings in a client with cirrhosis because they may indicate hepatic encephalopathy, a serious complication that requires immediate intervention. Peripheral edema (choice A) and increased abdominal girth (choice B) are common manifestations of cirrhosis but are not as acutely concerning as signs of hepatic encephalopathy. Yellowing of the skin (choice D) is due to jaundice, which is already present in the client and does not directly indicate a worsening condition like confusion and altered mental status.

5. After multiple attempts to stop drinking, an adult male is admitted to the medical intensive care unit (MICU) with delirium tremens. He is tachycardic, diaphoretic, restless, and disoriented. Which finding indicates a life-threatening condition?

• A. Widening QRS complexes and flat T waves
• B. Tachycardia and elevated blood pressure
• C. Restlessness and anxiety
• D. Diaphoresis and dehydration

Correct answer: A

Rationale: The correct answer is A: Widening QRS complexes and flat T waves. In the context of an adult male with delirium tremens and symptoms like tachycardia, diaphoresis, restlessness, and disorientation, the presence of widening QRS complexes and flat T waves on an ECG suggests severe electrolyte imbalance, particularly hypokalemia. This severe electrolyte imbalance can lead to life-threatening arrhythmias such as ventricular tachycardia or fibrillation. Tachycardia and elevated blood pressure (choice B) can be expected in delirium tremens but do not directly indicate a life-threatening condition as widening QRS complexes and flat T waves do. Restlessness and anxiety (choice C) are common symptoms of delirium tremens but do not specifically signify a life-threatening condition. Diaphoresis and dehydration (choice D) are also common in delirium tremens but do not directly point towards a life-threatening electrolyte imbalance as widening QRS complexes and flat T waves do.

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