Nursing Elites

1. After experiencing a left frontal lobe CVA, a fifty-five-year-old man is being monitored by a nurse. The patient's family is not present in the room. What should the nurse observe most closely for?

• A. Changes in emotion and behavior
• B. Monitor loss of hearing
• C. Observe appetite and vision deficits
• D. Changes in facial muscle control

Correct answer: A

Rationale: The correct answer is to watch for changes in emotion and behavior. The frontal lobe, particularly the left side, is responsible for regulating behavior and emotions. Therefore, following a left frontal lobe CVA, monitoring for alterations in emotion and behavior is crucial. Choices B, C, and D are incorrect because loss of hearing, appetite and vision deficits, and changes in facial muscle control are not directly associated with a left frontal lobe CVA.

2. Which type of cells secrete insulin?

• A. alpha cells
• B. beta cells
• C. CD4 cells
• D. helper cells

Correct answer: B

Rationale: Beta cells are responsible for secreting insulin. Insulin is produced by beta cells in the pancreas and plays a crucial role in regulating blood sugar levels. Alpha cells secrete glucagon, not insulin (Choice A). CD4 cells are a type of immune cell that helps coordinate the immune response (Choice C). Helper cells are a type of immune cell that aids in activating other immune cells (Choice D). Therefore, the correct answer is beta cells.

3. When planning care for a client taking Heparin, which nursing diagnosis should the nurse address first?

• A. Ineffective tissue perfusion related to the presence of a thrombus obstructing blood flow
• B. Risk for injury related to active loss of blood from the vascular space
• C. Deficient knowledge related to the client's lack of understanding of the disease process
• D. Impaired skin integrity related to the development of bruises and/or hematoma

Correct answer: B

Rationale: The correct answer is 'Risk for injury related to active loss of blood from the vascular space.' When a client is taking Heparin, the primary concern is the risk of bleeding due to its anticoagulant properties. Monitoring for signs of active blood loss is crucial to prevent complications like hemorrhage. While ineffective tissue perfusion, deficient knowledge, and impaired skin integrity are important, they are secondary to the immediate risk of bleeding in clients taking anticoagulants like Heparin.

4. A client receives a cervical intracavity radium implant as part of her therapy. A common side effect of a cervical implant is:

• A. creamy, pink-tinged vaginal drainage.
• B. stomatitis.
• C. constipation.
• D. xerostomia.

Correct answer: A

Rationale: The correct answer is 'creamy, pink-tinged vaginal drainage.' This side effect persists for 1 to 2 months after the removal of a cervical implant. Diarrhea, not constipation, is usually a side effect of cervical implants. Stomatitis and xerostomia are local side effects of radiation to the mouth, not associated with cervical implants. Therefore, choices B, C, and D are incorrect.

5. While assessing a patient in the ICU, a nurse observes signs of a weak pulse, quick respiration, acetone breath, and nausea. Which of the following conditions is most likely occurring?

• A. Hypoglycemic patient
• B. Hyperglycemic patient
• C. Cardiac arrest
• D. End-stage renal failure

Correct answer: B

Rationale: The correct answer is a hyperglycemic patient. The signs described - weak pulse, quick respiration, acetone breath, and nausea - are indicative of hyperglycemia. A hypoglycemic patient would typically present with different signs such as pale skin, sweating, and confusion. Cardiac arrest would manifest with sudden loss of heart function and consciousness, not the signs described. End-stage renal failure would present with symptoms related to kidney dysfunction like edema, fatigue, and changes in urine output, which are not mentioned in the scenario.

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