Nursing Elites

1. A nurse is caring for a client with Diabetes Insipidus. Which assessment finding warrants immediate intervention by the nurse?

• A. Hypernatremia
• B. Excessive thirst
• C. Elevated heart rate
• D. Poor skin turgor

Correct answer: A

Rationale: The correct answer is A: Hypernatremia. In a client with Diabetes Insipidus, hypernatremia, an elevated sodium level in the blood, can lead to neurological symptoms such as confusion, seizures, or coma. Immediate intervention is necessary to prevent these serious complications. Excessive thirst (choice B) is a common symptom of Diabetes Insipidus but does not require immediate intervention. Elevated heart rate (choice C) and poor skin turgor (choice D) are important assessments but are not as critical as hypernatremia in this context.

2. A client with cirrhosis is admitted with jaundice and ascites. Which clinical finding is most concerning?

• A. Increased abdominal girth
• B. Confusion and altered mental status
• C. Yellowing of the skin
• D. Peripheral edema

Correct answer: B

Rationale: Confusion and altered mental status are concerning in a client with cirrhosis as they may indicate hepatic encephalopathy, a serious complication that requires immediate intervention. Increased abdominal girth can be seen in ascites, yellowing of the skin is due to jaundice, and peripheral edema is associated with fluid retention in cirrhosis, but confusion and altered mental status are more closely linked to hepatic encephalopathy, which can progress rapidly and needs urgent attention.

3. When organizing home visits for the day, which older client should the home health nurse plan to visit first?

• A. A woman who takes naproxen (Naprosyn) and reports a recent onset of dark, tarry stools.
• B. A man who receives weekly injections of epoetin (Procrit) for a low serum iron level.
• C. A man with emphysema who smokes and is complaining of white patches in his mouth.
• D. A frail woman with heart failure who reported a 2-pound weight gain in the last week.

Correct answer: A

Rationale: The correct answer is A. Dark, tarry stools may indicate gastrointestinal bleeding, a potentially life-threatening condition that requires immediate attention. Visiting this client first is crucial for prompt assessment and intervention. Choices B, C, and D do not present immediate life-threatening conditions that require urgent attention compared to the potential emergency indicated by dark, tarry stools.

4. Which assessment is most important for the nurse to include in the daily plan of care for a client with a burned extremity?

• A. Distal pulse intensity
• B. Skin integrity
• C. Pain levels
• D. Range of motion

Correct answer: A

Rationale: The correct answer is A: Distal pulse intensity. Monitoring distal pulses is crucial to ensure that circulation to the extremity is not compromised. This assessment helps in detecting any signs of decreased circulation, which is vital in managing a burned extremity. While skin integrity (choice B), pain levels (choice C), and range of motion (choice D) are also important assessments, monitoring distal pulse intensity takes precedence as it directly reflects the perfusion status of the affected extremity in a burned client.

5. A client with cirrhosis is admitted with ascites and jaundice. Which clinical finding is most concerning?

• A. Peripheral edema
• B. Increased abdominal girth
• C. Confusion and altered mental status
• D. Yellowing of the skin

Correct answer: C

Rationale: The correct answer is C. Confusion and altered mental status are the most concerning clinical findings in a client with cirrhosis because they may indicate hepatic encephalopathy, a serious complication that requires immediate intervention. Peripheral edema (choice A) and increased abdominal girth (choice B) are common manifestations of cirrhosis but are not as acutely concerning as signs of hepatic encephalopathy. Yellowing of the skin (choice D) is due to jaundice, which is already present in the client and does not directly indicate a worsening condition like confusion and altered mental status.

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