Nursing Elites

1. A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab value is important for the nurse to review before contacting the health care provider?

• A. capillary glucose
• B. urine specific gravity
• C. Serum calcium
• D. white blood cell count

Correct answer: C

Rationale: The correct answer is C: Serum calcium. Numbness and tingling can be indicative of hypocalcemia, which can affect the nervous system. Reviewing serum calcium levels is crucial to address this potential issue. Options A, B, and D are not directly related to the symptoms described by the client and are not typically associated with numbness and tingling around the mouth and fingers. Capillary glucose levels are more relevant in assessing for diabetes or monitoring glucose control. Urine specific gravity is useful in evaluating hydration status. White blood cell count is typically checked to assess infection or immune response, which are not indicated by the client's symptoms of numbness and tingling.

2. In preparing a care plan for a client admitted with a diagnosis of Guillain-Barre syndrome, which nursing problem has the highest priority?

• A. Ineffective coping related to uncertainty of disease progression
• B. Imbalanced nutrition: less than body requirements related to impaired swallowing reflex
• C. Ineffective breathing pattern related to ascending paralysis
• D. Impaired physical mobility related to asymmetrical descending paralysis

Correct answer: C

Rationale: Ineffective breathing pattern is the highest priority nursing problem for a client with Guillain-Barre syndrome due to the potential risk of respiratory failure. As the paralysis ascends, it can affect the muscles needed for breathing, leading to respiratory compromise. Addressing this problem promptly is crucial to prevent respiratory distress and failure. Choices A, B, and D are also important nursing problems in Guillain-Barre syndrome, but ensuring effective breathing takes precedence over coping, nutrition, and mobility due to the immediate threat it poses to the client's life.

3. An older female client living in a low-income apartment complex tells the home health nurse that she is concerned about her 81-year-old neighbor, a widow whose son recently assumed her financial affairs. Lately, her neighbor has become reclusive but is occasionally seen walking outside wearing only a robe and slippers. What response should the nurse offer?

• A. Explain that it is not unusual for older adults to suffer from dementia, which often causes such behaviors.
• B. Tell the client to talk to a healthcare provider before reporting suspicion of neglect to the authorities.
• C. Provide the number for Adult Protective Services so the client can report any suspicion of elder abuse.
• D. Encourage the client to avoid becoming involved in the neighbor’s problems for one’s protection.

Correct answer: C

Rationale: The correct response is to provide the number for Adult Protective Services so the client can report any suspicion of elder abuse. This action allows for an official investigation into possible elder abuse or neglect, ensuring the neighbor’s safety and well-being. Choice A is incorrect because assuming dementia without evidence is premature and could lead to overlooking potential abuse. Choice B is incorrect as the situation raises concerns about possible neglect or abuse, which should be reported promptly to the appropriate authorities. Choice D is incorrect as it dismisses the importance of ensuring the safety and well-being of the neighbor in need.

4. A new mother asks the nurse if the newborn infant has an infection because the healthcare provider prescribed a blood test called the TORCH screen test. Which response should the nurse offer to the mother's inquiry?

• A. Rising titers identify the etiology of certain neuro-sensory birth defects
• B. The screen determines the risk for inherited anomalies in the newborn
• C. The test identifies the correct antibiotic to give the newborn for an infection
• D. Exposure to infections that can cross the placenta cause a positive antibody titer

Correct answer: D

Rationale: The TORCH screen test is used to detect infections that can affect the newborn by showing if there was exposure to these infections. Choice A is incorrect because the TORCH screen test is not specifically for identifying the etiology of neuro-sensory birth defects. Choice B is incorrect because the test does not determine the risk for inherited anomalies. Choice C is incorrect because the test is not used to identify the correct antibiotic for an infection, but rather to detect infections that may have affected the newborn.

5. A high school football player comes to the clinic complaining of severe acne. The mother reports recent behavior changes, including irritability and suspiciousness of friends. The nurse’s assessment reveals an elevated blood pressure. Which intervention should the nurse implement first?

• A. Encourage the client to see a dermatologist
• B. Refer the adolescent to a substance abuse program
• C. Suggest a low-salt, low-fat, and caffeine-free diet
• D. Inquire about a possible use of anabolic steroids

Correct answer: D

Rationale: In this scenario, the high school football player presenting with severe acne, behavior changes, elevated blood pressure, and suspicion of friends suggests the possible use of anabolic steroids. Anabolic steroid use can lead to such symptoms. Therefore, the nurse should first inquire about the possible use of anabolic steroids to address the root cause of the presenting issues. Encouraging the client to see a dermatologist (Choice A) may be necessary but addressing the underlying cause is crucial first. Referring the adolescent to a substance abuse program (Choice B) is premature without confirming steroid use. Suggesting a low-salt, low-fat, and caffeine-free diet (Choice C) is not the priority in this situation where a serious issue like anabolic steroid use needs immediate attention.

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