Nursing Elites

1. A male client with schizophrenia tells the nurse that the hospital has installed cameras that watch him and listening devices that record what everyone says. Which nursing problem should the nurse document for this client?

• A. Noncompliance with medication related to thought broadcasting
• B. Situational self-esteem disturbance secondary to schizophrenia
• C. Disturbed sensory perception related to auditory hallucinations
• D. Impaired environmental interpretation related to paranoid delusions

Correct answer: D

Rationale: The correct answer is D: Impaired environmental interpretation related to paranoid delusions. The client's belief about cameras watching and recording him is a manifestation of paranoid delusions, indicating a misinterpretation of the environment. Choice A is incorrect because thought broadcasting is not directly related to the client's belief about surveillance equipment. Choice B is incorrect as self-esteem disturbance is not the primary issue presented. Choice C is also incorrect as the client is not experiencing auditory hallucinations but rather paranoid delusions about surveillance.

2. Following morning care, a client with C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implement first?

• A. Check for any kinks or obstructions in the client’s Foley tubing
• B. Assess the client’s blood pressure every 15 minutes
• C. Administer a prescribed PRN dose of hydralazine (Apresoline)
• D. Educate the client on recognizing symptoms of dysreflexia

Correct answer: B

Rationale: In a client with a C-5 spinal cord injury experiencing flushing and a headache, the priority intervention is to assess the client's blood pressure every 15 minutes. These symptoms could indicate autonomic dysreflexia, a potentially life-threatening condition. Assessing the blood pressure is crucial to identify and address this emergency situation promptly. Checking for kinks or obstructions in the Foley tubing (Choice A) is important but not the priority in this scenario. Administering hydralazine (Choice C) without knowing the blood pressure could be harmful as it may lead to a sudden drop in blood pressure. Educating the client on recognizing symptoms of dysreflexia (Choice D) is important for long-term management but is not the immediate action needed in this acute situation.

3. The nurse notes that an older adult client has a moist cough that increases in severity during and after meals. Based on this finding, what action should the nurse take?

• A. Encourage the client to perform deep breathing exercises daily.
• B. Offer the client additional clear fluids frequently.
• C. Collect a sputum specimen immediately.
• D. Request a consultation to confirm dysphagia

Correct answer: D

Rationale: The correct answer is D. The moist cough that worsens during and after meals suggests possible dysphagia, a condition related to swallowing difficulties. Requesting a consultation for dysphagia is essential for an accurate diagnosis and appropriate management. Encouraging the client to perform deep breathing exercises (choice A) may not address the underlying issue of dysphagia. Offering additional clear fluids (choice B) may not be appropriate for someone with swallowing difficulties. Collecting a sputum specimen (choice C) is not the priority in this scenario as the focus should be on identifying and managing the swallowing problem.

4. The healthcare provider is evaluating a client for potential dehydration. Which assessment finding is most indicative of fluid volume deficit?

• A. Moist mucous membranes
• B. Increased urine output
• C. Decreased skin turgor
• D. Elevated blood pressure

Correct answer: C

Rationale: Corrected Rationale: Decreased skin turgor is a classic sign of dehydration. When someone is dehydrated, the skin loses its elasticity and becomes less turgid. This change is easily assessed by gently pinching and pulling up the skin on the back of the hand or forearm. If the skin remains elevated or tents rather than quickly returning to its normal position, it indicates dehydration. Moist mucous membranes (Choice A) are actually a sign of adequate hydration. Increased urine output (Choice B) can be a sign of dehydration, but decreased skin turgor is a more specific indicator. Elevated blood pressure (Choice D) is not typically associated with fluid volume deficit and may indicate other health issues.

5. A client with multiple sclerosis is experiencing scotomas (blind spots), which are limiting peripheral vision. What intervention should the nurse include in this client's plan of care?

• A. Encourage the use of corrective lenses during the day
• B. Practice visual exercises that focus on a still object
• C. Alternate an eye patch from eye every 2 hours
• D. Teach techniques for scanning the environment

Correct answer: D

Rationale: The correct intervention for a client with multiple sclerosis experiencing scotomas and limited peripheral vision is to teach techniques for scanning the environment. This intervention helps the client compensate for vision loss by learning how to scan and explore their surroundings effectively. Encouraging the use of corrective lenses may not address the issue of scotomas, and visual exercises focusing on a still object may not enhance peripheral vision. Alternating an eye patch every 2 hours is not typically indicated for scotomas in multiple sclerosis, making it an incorrect choice.

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