Nursing Elites

1. A client with hepatic encephalopathy exhibits confusion, difficulty arousing from sleep, and rigid extremities. Based on these clinical findings, what stage of hepatic encephalopathy should the nurse document?

• A. Stage 1
• B. Stage 2
• C. Stage 3
• D. Stage 4

Correct answer: C

Rationale: Stage 3 hepatic encephalopathy is characterized by confusion, difficulty arousing from sleep, and rigidity of extremities. These symptoms indicate advanced manifestations of hepatic encephalopathy, requiring prompt intervention and monitoring to prevent further neurological deterioration.

2. A client with newly diagnosed type 2 diabetes is preparing for discharge. Which statement by the client indicates a need for further teaching?

• A. I will take my insulin shots only when my blood sugar is high
• B. I need to follow a balanced diet and exercise regularly
• C. I should monitor my blood sugar levels regularly
• D. I need to take my medication as prescribed by my doctor

Correct answer: A

Rationale: In type 2 diabetes, insulin therapy is typically not the first-line treatment. Patients should follow their prescribed treatment plan, which may or may not include insulin. Taking insulin shots only when blood sugar is high can lead to uncontrolled glucose levels and complications. It is important to adhere to the prescribed medication regimen to manage diabetes effectively.

3. What should be monitored to evaluate the effectiveness of enoxaparin in a patient with deep vein thrombosis (DVT)?

• A. Prothrombin time (PT)
• B. Partial thromboplastin time (PTT)
• C. International normalized ratio (INR)
• D. Platelet count

Correct answer: C

Rationale: The international normalized ratio (INR) is the appropriate parameter to monitor the effectiveness of enoxaparin in preventing clot formation in patients with deep vein thrombosis (DVT). INR reflects the clotting ability of the blood and is commonly used to assess the therapeutic range of anticoagulant medications, such as enoxaparin, which is crucial in managing and preventing thrombotic events like DVT.

4. A client with a severe head injury is admitted to the intensive care unit (ICU). Which finding should the nurse report to the healthcare provider immediately?

• A. Urine output of 100 mL/hour.
• B. Intracranial pressure (ICP) of 20 mm Hg.
• C. Respiratory rate of 12 breaths/minute.
• D. Mean arterial pressure (MAP) of 70 mm Hg.

Correct answer: B

Rationale: An Intracranial Pressure (ICP) of 20 mm Hg is at the upper limit of normal and may indicate increased intracranial pressure, which is a critical finding in a client with a severe head injury. Elevated ICP can lead to further brain damage and must be addressed promptly to prevent complications such as herniation. Monitoring and managing ICP are crucial in the care of patients with head injuries in the ICU.

5. A client with chronic kidney disease is prescribed a low-protein diet. Which laboratory result should the nurse monitor to evaluate the effectiveness of the diet?

• A. Blood urea nitrogen (BUN)
• B. Serum potassium
• C. Serum calcium
• D. Creatinine clearance

Correct answer: A

Rationale: Blood urea nitrogen (BUN) levels should be monitored to assess the effectiveness of a low-protein diet in clients with chronic kidney disease. BUN levels reflect the breakdown of protein in the body, and a low-protein diet aims to reduce BUN levels to lessen the workload on the kidneys. Therefore, monitoring BUN levels is crucial in managing kidney function and evaluating the impact of dietary modifications. Serum potassium, serum calcium, and creatinine clearance are important parameters to monitor in clients with chronic kidney disease, but they are not specifically indicative of the effectiveness of a low-protein diet. Serum potassium levels are crucial in assessing electrolyte balance, serum calcium levels are important for bone health and nerve function, and creatinine clearance reflects kidney function overall, not just the impact of a low-protein diet.

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