Nursing Elites

1. In a client with liver cirrhosis experiencing confusion and disorientation, what condition is most likely causing these symptoms?

• A. Hepatic encephalopathy
• B. Hypoglycemia
• C. Electrolyte imbalance
• D. Dehydration

Correct answer: A

Rationale: Hepatic encephalopathy is the most likely condition causing confusion and disorientation in a client with liver cirrhosis. This condition is a common complication of liver cirrhosis and is characterized by cognitive impairment due to elevated ammonia levels in the blood. The build-up of ammonia affects brain function, leading to symptoms such as confusion, disorientation, and altered consciousness. Hypoglycemia (choice B) may present with confusion but is less likely in a client with liver cirrhosis without a history of diabetes or insulin use. Electrolyte imbalance (choice C) and dehydration (choice D) can contribute to confusion but are not the primary causes in a client with liver cirrhosis experiencing these symptoms.

2. An older adult with a diagnosis of Alzheimer's disease has been experiencing fecal incontinence, with no recent change in stool character noted by the nurse. What is the nurse's most appropriate intervention?

• A. Keep a food diary to identify foods that worsen the client's symptoms
• B. Provide the client with a bland, low-residue diet
• C. Toilet the client on a frequent, scheduled basis
• D. Collaborate with the primary provider to secure an order for loperamide

Correct answer: C

Rationale: The most appropriate intervention for an older adult with Alzheimer's disease experiencing fecal incontinence and no change in stool character is to toilet the client on a frequent, scheduled basis. Scheduled toileting can help manage incontinence by establishing a routine for bowel movements, which may aid in reducing episodes of fecal incontinence.

3. An elderly client with congestive heart failure (CHF) is admitted to the hospital. Which laboratory test result should the nurse expect to find?

• A. Elevated serum sodium level.
• B. Decreased brain natriuretic peptide (BNP) level.
• C. Increased serum creatinine level.
• D. Elevated hemoglobin and hematocrit levels.

Correct answer: C

Rationale: In clients with congestive heart failure (CHF), impaired cardiac function can lead to decreased renal perfusion, resulting in elevated serum creatinine levels. Therefore, an increased serum creatinine level is a common laboratory finding in CHF clients, indicating possible renal impairment.

4. What physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?

• A. Soft, spongy fundus.
• B. Saturating two perineal pads per hour.
• C. Pulse rate of 56 BPM.
• D. Unilateral lower leg pain.

Correct answer: C

Rationale: The correct answer is C. A pulse rate of 56 BPM can be considered a normal finding for a primigravida client who is 12 hours postpartum. Postpartum bradycardia can occur due to increased stroke volume and decreased vascular resistance after delivery. It is important for the nurse to monitor the client's vital signs and recognize that a lower pulse rate can be expected in the immediate postpartum period. Choices A, B, and D are incorrect because a soft, spongy fundus may indicate uterine atony, saturating two perineal pads per hour is excessive bleeding, and unilateral lower leg pain could suggest deep vein thrombosis, all of which would require further assessment and intervention.

5. The nurse is planning care for a 16-year-old with juvenile rheumatoid arthritis (JRA). The nurse includes activities to strengthen and mobilize the joints and surrounding muscles. Which physical therapy regimen should the nurse encourage the adolescent to implement?

• A. Exercise in a swimming pool.
• B. Splint affected joints during activity.
• C. Perform passive range of motion exercises twice daily.
• D. Begin a training program of lifting weights and running.

Correct answer: A

Rationale: Exercising in a swimming pool is beneficial for adolescents with juvenile rheumatoid arthritis as it reduces stress on the joints while allowing movement and strengthening. The buoyancy of water supports the body, making exercises easier and less painful, while also providing resistance to strengthen muscles. This form of exercise can help improve joint mobility and overall function without causing excessive strain on the joints. Choices B, C, and D are incorrect because splinting affected joints, performing passive range of motion exercises, or beginning a training program of lifting weights and running can potentially exacerbate symptoms and cause additional stress on the joints, which is not recommended for individuals with juvenile rheumatoid arthritis.

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