Nursing Elites

1. A male client with schizophrenia is jerking his neck and smacking his lips. Which finding indicates to the nurse that he is experiencing an irreversible side effect of antipsychotic agents?

• A. Cramping muscular pain
• B. Worming movements of the tongue
• C. Decreased tendon reflexes
• D. Dry oral mucous membranes

Correct answer: B

Rationale: The correct answer is B: Worming movements of the tongue. Worming movements of the tongue, known as tardive dyskinesia, are an irreversible side effect of antipsychotic medications. Tardive dyskinesia is characterized by involuntary, repetitive movements of the tongue, lips, face, trunk, and extremities. Cramping muscular pain (Choice A) is more indicative of dystonia, an extrapyramidal side effect that can be treated effectively with antiparkinsonian medications. Decreased tendon reflexes (Choice C) are not typically associated with irreversible side effects of antipsychotic agents. Dry oral mucous membranes (Choice D) are not specific to irreversible side effects of antipsychotic medications.

2. A female client is admitted for a diabetic crisis resulting from inadequate dietary practices. After stabilization, the nurse talks to the client about her prescribed diet. What client characteristic is most important for successful adherence to the diabetic diet?

• A. Understands the importance of timing insulin administration 30 minutes before eating
• B. Frequently includes fruits and vegetables in meals and snacks
• C. Has access to someone who can assist with meal preparation and monitoring
• D. Demonstrates willingness to consistently follow the prescribed diet

Correct answer: D

Rationale: The most crucial characteristic for successful adherence to a diabetic diet is the client's willingness to consistently follow the prescribed diet plan. Option A, understanding insulin timing, is important for treatment but not directly related to dietary adherence. Option B, consuming fruits and vegetables, is a healthy practice but does not ensure adherence to a specific diabetic diet. Option C, having assistance with meal preparation, is beneficial but not as essential as the client's personal commitment to adhering to the diet consistently.

3. The nurse is caring for a newborn who arrives in the nursery following a precipitous birth on the way to the hospital. A drug screen of the mother reveals the presence of cocaine metabolites. The infant has a heart rate of 175 beats/minute, cries continuously, is irritable, and is hyperreactive to stimuli. Which intervention is most important for the nurse to include in this infant’s plan of care?

• A. Initiate infant sepsis protocol
• B. Implement seizure precautions
• C. Refer to protective child services
• D. Formula feed every 3 hours

Correct answer: B

Rationale: The infant's symptoms, such as a high heart rate, continuous crying, irritability, and hyperreactivity, suggest possible withdrawal effects due to maternal cocaine use. These symptoms can lead to seizures. Therefore, the priority intervention is to implement seizure precautions to ensure the infant's safety. Initiating the infant sepsis protocol is not indicated based on the symptoms presented. Referring to protective child services is important but not the immediate priority. Formula feeding every 3 hours is a routine care measure but does not address the urgent need to prevent potential seizures.

4. The nurse is assigned to care for a client diagnosed with psoriasis. What behavior by the nurse addresses this client's psychosocial need for acceptance?

• A. Wearing gloves when providing care to the client
• B. Encouraging the client to join a support group
• C. Shaking hands with the client during an introduction
• D. Allowing the client to express their feelings openly

Correct answer: B

Rationale: Encouraging the client to join a support group is the best option to address the client's psychosocial need for acceptance. Support groups provide a sense of belonging, understanding, and acceptance from peers who share similar experiences. This helps the client feel accepted despite their condition. Wearing gloves when providing care, shaking hands during an introduction, and allowing the client to express feelings openly are important but do not directly address the client's need for acceptance.

5. The nurse is assessing an older adult with type 2 diabetes. Which assessment finding indicates that the client understands long-term control of diabetes?

• A. The fasting blood sugar was 120 mg/dL this morning
• B. Urine ketones have been negative for the past 6 months
• C. The hemoglobin A1C was 6.5% last week
• D. No diabetic ketoacidosis has occurred in 6 months

Correct answer: C

Rationale: An A1C level of 6.5% indicates good long-term control of diabetes as it reflects the average blood sugar levels over the past 2-3 months. Monitoring fasting blood sugar provides immediate information about the current blood sugar level, while the absence of urine ketones indicates short-term control. Although the absence of diabetic ketoacidosis is positive, it doesn't specifically reflect long-term control like the A1C level does.

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