Nursing Elites

1. A combination multi-drug cocktail is being considered for an asymptomatic HIV-infected client with a CD4 cell count of 500. Which nursing assessment of the client is most crucial in determining whether therapy should be initiated?

• A. Presence of viral symptoms
• B. Engages in high-risk behaviors
• C. Willingness to comply with complex drug schedules
• D. History of opportunistic infections

Correct answer: C

Rationale: The most crucial nursing assessment in determining whether therapy should be initiated for an asymptomatic HIV-infected client with a CD4 cell count of 500 is the client's willingness to comply with complex drug schedules. Adherence to antiretroviral therapy is essential for its effectiveness. Assessing the client's willingness and ability to comply with the complex medication regimen is crucial to ensure successful treatment and prevent drug resistance. Choices A, B, and D, although important in the overall care of the client, are not as crucial as assessing the client's willingness to adhere to the prescribed drug regimen.

2. The nurse is assessing a client with a history of schizophrenia who reports feeling sedated after starting a new antipsychotic medication. Which intervention is most appropriate?

• A. Reassure the client that sedation will subside with continued use
• B. Instruct the client to take the medication at bedtime
• C. Teach the client to take the medication with food
• D. Consult the healthcare provider to reduce the dosage

Correct answer: B

Rationale: Instructing the client to take the medication at bedtime is the most appropriate intervention. Taking antipsychotic medications at bedtime can help reduce the impact of sedation on the client's daily activities. This approach allows the client to sleep through the sedative effects. Choice A is incorrect because just reassuring the client may not address the immediate issue of sedation. Choice C is incorrect as taking the medication with food does not directly address the sedation concern. Choice D is not the first-line intervention; adjusting the dosage should be done by the healthcare provider after assessing the client's response to the medication.

3. After a spider bite on the lower extremity, a client is admitted to treat an infection that is spreading up the leg. Which admission assessment findings should the nurse report to the healthcare provider?

• A. Swollen lymph nodes in the groin
• B. Core body temperature of 100.5°F
• C. All of the above
• D. Elevated white blood cell count

Correct answer: C

Rationale: All of the above findings should be reported to the healthcare provider for prompt evaluation and treatment. Swollen lymph nodes in the groin indicate regional lymphatic involvement, a core body temperature of 100.5°F suggests a mild fever response, and an elevated white blood cell count indicates an ongoing infection process. These findings collectively point towards the spread of infection and require immediate attention to prevent further complications.

4. Which self-care measure is most important for the nurse to include in the plan of care of a client recently diagnosed with type 2 diabetes mellitus?

• A. Maintaining a low-sugar diet
• B. Foot care
• C. Blood glucose monitoring
• D. Daily exercise

Correct answer: C

Rationale: Blood glucose monitoring is crucial for managing diabetes effectively. By monitoring blood sugar levels, individuals can understand how their lifestyle choices, medications, and diet affect their glucose levels. This information helps in making necessary adjustments to control blood sugar levels and prevent complications. While maintaining a low-sugar diet, foot care, and daily exercise are all important aspects of managing diabetes, blood glucose monitoring takes precedence as it provides real-time data for informed decision-making.

5. A client is admitted with a large bowel obstruction. What finding should the nurse report immediately?

• A. Absence of bowel sounds in all four quadrants.
• B. Abdominal distention with a firm, rigid abdomen.
• C. Frequent, small, liquid stools.
• D. Nausea and vomiting that worsens after meals.

Correct answer: B

Rationale: Abdominal distention with a firm, rigid abdomen is a concerning sign that may indicate perforation, which requires immediate intervention. The rigidity suggests a complication of the large bowel obstruction. Absence of bowel sounds in all four quadrants, option A, is a common finding in a bowel obstruction but not as alarming as a rigid abdomen. Frequent, small, liquid stools, option C, are not typical findings in a large bowel obstruction; instead, constipation is more common. Nausea and vomiting that worsens after meals, option D, are also common symptoms of a bowel obstruction but do not indicate an immediate life-threatening complication like a perforation.

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