Nursing Elites

1. A nurse in an emergency department completes an assessment on an adolescent client with conduct disorder. The client threatened suicide to a teacher at school. Which of the following statements should the nurse include in the assessment?

• A. Tell me about your siblings
• B. Tell me what kind of music you like
• C. Tell me how often you drink alcohol
• D. Tell me about your school schedule

Correct answer: C

Rationale: Asking about alcohol intake is crucial in assessing the client's risk factors and behaviors, especially in the context of a suicide threat. Understanding alcohol consumption patterns can help the nurse evaluate potential substance abuse issues and their impact on the client's mental health. Choices A, B, and D are less pertinent to the immediate concern of assessing suicide risk and conduct disorder symptoms.

2. A nurse is assessing a client who has pericarditis. Which of the following findings is the priority?

• A. Paradoxical pulse
• B. Dependent edema
• C. Pericardial friction rub
• D. Substernal chest pain

Correct answer: A

Rationale: In a client with pericarditis, the priority finding is a paradoxical pulse. This is a crucial sign of cardiac tamponade, a life-threatening complication of pericarditis where fluid accumulates in the pericardial sac, causing compression of the heart. A paradoxical pulse is an exaggerated decrease in systolic blood pressure (>10 mmHg) during inspiration. Prompt recognition and intervention are essential to prevent hemodynamic instability and cardiac arrest. Dependent edema (choice B) is not typically associated with pericarditis. Pericardial friction rub (choice C) is a common finding in pericarditis but does not indicate the urgency of intervention as a paradoxical pulse. Substernal chest pain (choice D) is a classic symptom of pericarditis but is not as critical as a paradoxical pulse in the context of assessing for complications.

3. A nurse is reviewing the medical record of a client who has hypothyroidism. Which of the following findings should the nurse expect?

• A. Weight gain of 1.4 kg (3 lb) in the past 2 weeks.
• B. Exophthalmos.
• C. Tachycardia.
• D. Heat intolerance.

Correct answer: A

Rationale: The correct answer is A. Weight gain can indicate myxedema, which is a symptom commonly seen in hypothyroidism. Exophthalmos (choice B) is actually a characteristic finding of hyperthyroidism, not hypothyroidism. Tachycardia (choice C) and heat intolerance (choice D) are also more indicative of hyperthyroidism rather than hypothyroidism.

4. A nurse is developing a care plan for a client who is receiving nitroprusside for severe hypertension. Which action should the nurse include?

• A. Administer calcium gluconate at the bedside.
• B. Monitor blood pressure every 2 hours.
• C. Limit light exposure to the infusion.
• D. Keep the client on NPO status.

Correct answer: C

Rationale: The correct action the nurse should include in the care plan for a client receiving nitroprusside for severe hypertension is to limit light exposure to the infusion. Nitroprusside is light-sensitive, so it should be protected from light exposure to prevent degradation. Administering calcium gluconate at the bedside is not directly related to nitroprusside administration. Monitoring blood pressure every 2 hours is a good practice but is not specifically related to the administration of nitroprusside. Keeping the client on NPO status is not necessary solely based on receiving nitroprusside.

5. A nurse is caring for a client who is 2 days postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Serosanguineous wound drainage
• B. Heart rate of 90/min
• C. Urine output of 30 mL/hr
• D. Temperature of 37.3°C (99.1°F)

Correct answer: C

Rationale: A urine output of 30 mL/hr is significantly low and indicates possible renal impairment or inadequate perfusion to the kidneys, which are critical for postoperative recovery. In this situation, decreased urine output could lead to fluid and electrolyte imbalances, affecting the client's overall condition. The nurse should report this finding promptly to the healthcare provider for further evaluation and intervention. Serosanguineous wound drainage is a normal finding in the early postoperative period and does not typically warrant immediate concern. A heart rate of 90/min is within the normal range and may be expected in a postoperative client due to the stress response. A temperature of 37.3°C (99.1°F) is slightly elevated but not a concerning finding in isolation postoperatively.

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