Nursing Elites

1. A client with diabetes mellitus is experiencing polyuria, polydipsia, and polyphagia. What do these symptoms indicate?

• A. Hypoglycemia
• B. Diabetic ketoacidosis (DKA)
• C. Hyperosmolar hyperglycemic state (HHS)
• D. Insulin shock

Correct answer: B

Rationale: Polyuria, polydipsia, and polyphagia are classic signs of diabetic ketoacidosis (DKA), which occurs due to a combination of hyperglycemia and ketone production. Hypoglycemia (Choice A) is characterized by low blood sugar levels, leading to symptoms like confusion, shakiness, and sweating, which are different from the symptoms described in the scenario. Hyperosmolar hyperglycemic state (HHS) (Choice C) typically presents with severe hyperglycemia, dehydration, and altered mental status, rather than the triad of symptoms mentioned. Insulin shock (Choice D) refers to a severe hypoglycemic reaction due to excessive insulin, manifesting with confusion, sweating, and rapid heartbeat, not the symptoms seen in the client with diabetes mellitus described in this scenario.

2. Parents of a school-age child ask the nurse for suggestions in helping the child who is demonstrating school avoidance. What is an appropriate suggestion by the nurse?

• A. Take the child to the healthcare provider for testing.
• B. Be firm and insist the child go to school.
• C. Allow the child to stay home and rest.
• D. Consult with the teacher at school.

Correct answer: B

Rationale: When a child is demonstrating school avoidance, it is important for parents to be firm and insist that the child go to school. This helps establish a routine and prevents the behavior from becoming a pattern. Taking the child to the healthcare provider for testing (Choice A) may not be necessary at this stage as school avoidance is a behavioral issue. Allowing the child to stay home and rest (Choice C) may reinforce the avoidance behavior. While consulting with the teacher at school (Choice D) is important, the immediate focus should be on addressing the avoidance behavior at home.

3. On the first postoperative day, the nurse finds an older male client disoriented and trying to climb over the bed railing. Previously, he was oriented to person, place, and time on admission. Which intervention should the nurse implement first?

• A. Administer a sedative.
• B. Determine the client’s blood pressure.
• C. Apply soft restraints.
• D. Call for assistance.

Correct answer: B

Rationale: The correct intervention the nurse should implement first is to determine the client’s blood pressure. Assessing the blood pressure is crucial in this situation to rule out physiological causes like hypotension leading to the client's disorientation. Administering a sedative (Choice A) without understanding the underlying cause may worsen the situation. Applying soft restraints (Choice C) should not be the initial action and can be considered later if necessary. Calling for assistance (Choice D) may be needed eventually, but assessing the client's blood pressure takes precedence to address the immediate concern.

4. During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?

• A. An old friend with eczema came for a visit.
• B. Recently received an influenza immunization.
• C. A grandson and his new dog recently visited.
• D. Corticosteroid cream was applied to eczema.

Correct answer: C

Rationale: The correct answer is C. Contact with the grandson's new dog could have introduced new allergens or irritants, exacerbating the eczema symptoms. Choice A is unrelated to the exacerbation of symptoms. Choice B, receiving an influenza immunization, is unlikely to directly cause an exacerbation of eczema symptoms. Choice D, applying corticosteroid cream, is a common treatment for eczema and would not likely be the cause of the exacerbation.

5. Which nursing diagnosis should be selected for a client who is receiving thrombolytic infusions for treatment of an acute myocardial infarction?

• A. Risk for infection related to thrombolysis.
• B. Risk for fluid volume deficit related to thrombolysis.
• C. Risk for impaired skin integrity related to thrombolysis.
• D. Risk for injury related to effects of thrombolysis.

Correct answer: D

Rationale: Thrombolytic therapy increases the risk of bleeding, not infection, fluid volume deficit, or impaired skin integrity. The most significant concern with thrombolytic therapy is the potential for bleeding complications, which can lead to various injuries. Therefore, 'Risk for injury related to effects of thrombolysis' is the most appropriate nursing diagnosis in this scenario. Choices A, B, and C are incorrect as they do not directly correlate with the primary risk associated with thrombolytic therapy.

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