Nursing Elites

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

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

Correct answer: B

Rationale: Confusion and altered mental status are concerning in a client with cirrhosis as they may indicate hepatic encephalopathy, a serious complication that requires immediate intervention. Increased abdominal girth can be seen in ascites, yellowing of the skin is due to jaundice, and peripheral edema is associated with fluid retention in cirrhosis, but confusion and altered mental status are more closely linked to hepatic encephalopathy, which can progress rapidly and needs urgent attention.

2. A newly graduated female staff nurse approaches the nurse manager and requests reassignment to another client because a male client is asking her for a date and making suggestive comments. Which response is best for the nurse manager to provide?

• A. I have to call the supervisor to get someone else to transfer to this unit to care for him.
• B. I know you are a good nurse and can handle this client in a professional manner.
• C. I'll talk to the client about his sexual harassment and insist that he stop immediately.
• D. I'll change your assignment, but let's talk about how a nurse should respond to this kind of client.

Correct answer: D

Rationale: The best response for the nurse manager is option D. Changing the assignment while providing guidance on professional boundaries and how to handle such situations is essential. Option A is not appropriate as it does not address the issue of the client's behavior. Option B, although supportive, does not offer a solution to the problem at hand. Option C is not the best approach as directly confronting the client about sexual harassment may escalate the situation further.

3. A client with urticaria due to environmental allergies is taking diphenhydramine. Which complaint should the nurse identify as a side effect of the OTC medication?

• A. Nausea and indigestion.
• B. Hypersalivation.
• C. Eyelid and facial twitching.
• D. Increased appetite.

Correct answer: A

Rationale: The correct answer is A: Nausea and indigestion. Diphenhydramine, an antihistamine, commonly causes gastrointestinal side effects such as nausea and indigestion. This medication can have anticholinergic effects, leading to these symptoms. Choices B, C, and D are incorrect because hypersalivation, eyelid and facial twitching, and increased appetite are not typically associated with diphenhydramine use.

4. The nurse reviews the laboratory findings of a client with an open fracture of the tibia. The white blood cell (WBC) count and erythrocyte sedimentation rate (ESR) are elevated. Before reporting this information to the healthcare provider, what assessment should the nurse obtain?

• A. Appearance of wound
• B. Pain level
• C. Presence of fever
• D. Mobility status

Correct answer: A

Rationale: The correct answer is A: Appearance of wound. Elevated WBC and ESR levels suggest a possible infection in the client with an open fracture. Assessing the wound's appearance is crucial to evaluate for signs of infection, such as redness, warmth, swelling, or drainage. By assessing the wound first, the nurse can provide important information to the healthcare provider regarding the potential infection, which may require immediate intervention. Choices B, C, and D are important assessments in caring for a client with an open fracture; however, in this scenario, the priority is to assess the wound for signs of infection due to the elevated WBC and ESR levels.

5. The nurse is assessing a client with left-sided heart failure. Which finding is most concerning?

• A. Jugular venous distention
• B. Crackles in the lungs
• C. Shortness of breath
• D. Peripheral edema

Correct answer: C

Rationale: Shortness of breath is most concerning in a client with left-sided heart failure as it indicates pulmonary congestion, requiring immediate intervention. Jugular venous distention (Choice A) is a sign of increased central venous pressure but is not as concerning as pulmonary congestion. Crackles in the lungs (Choice B) are common in heart failure due to fluid accumulation but are not as immediately concerning as severe shortness of breath. Peripheral edema (Choice D) is a manifestation of fluid retention in the body but is less indicative of acute pulmonary distress compared to shortness of breath.

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