Nursing Elites

1. A nurse is collecting data from a client who has myasthenia gravis (MG). Which of the following images should the nurse identify as an indication that the client is experiencing ptosis?

• A. Drooping eyelids
• B. Unequal pupils
• C. Facial twitching
• D. Facial droop

Correct answer: A

Rationale: The correct answer is A: 'Drooping eyelids.' Ptosis, characterized by drooping of the eyelid, is a classic symptom seen in myasthenia gravis. This occurs due to muscle weakness, particularly in the muscles that control eyelid movement. Choice B, 'Unequal pupils,' is not associated with ptosis and may indicate other neurological issues. Choice C, 'Facial twitching,' is not a typical sign of ptosis but could be related to other conditions like nerve irritation. Choice D, 'Facial droop,' is more commonly seen in conditions affecting the facial nerve, like Bell's palsy, and is not a characteristic feature of myasthenia gravis.

2. A nurse in a long-term care facility is serving on the ethics committee, which is addressing a client care dilemma. Which of the following strategies will facilitate resolving the dilemma?

• A. Ensure client autonomy only
• B. Consider only medical benefits
• C. Ensure clear communication among the health care team
• D. Identify possible solutions

Correct answer: D

Rationale: In resolving ethical dilemmas, it is essential to identify possible solutions to address the client care dilemma effectively. Option A, 'Ensure client autonomy only,' is not comprehensive enough to resolve complex ethical issues. Option B, 'Consider only medical benefits,' overlooks other important factors beyond medical benefits that are involved in ethical decision-making. Option C, 'Ensure clear communication among the health care team,' is important but may not be sufficient on its own to resolve the ethical dilemma. Therefore, the most effective strategy among the given options is to identify possible solutions to navigate through the ethical dilemma.

3. How should a healthcare provider manage a patient with sepsis?

• A. Administer IV antibiotics
• B. Monitor vital signs
• C. Administer fluids
• D. All of the above

Correct answer: D

Rationale: Managing a patient with sepsis requires a multi-faceted approach. Administering IV antibiotics is crucial to combat the underlying infection. Monitoring vital signs such as heart rate, blood pressure, respiratory rate, and temperature helps assess the patient's response to treatment and identify any deterioration. Administering fluids is essential to maintain adequate blood pressure and organ perfusion. Therefore, all the options are integral components of sepsis management, making 'All of the above' the correct answer. Choices A, B, and C are all essential in the comprehensive care of a patient with sepsis. Omitting any of these aspects can lead to suboptimal outcomes, as each plays a critical role in addressing different aspects of sepsis management.

4. What are the early signs of a pulmonary embolism?

• A. Chest pain, shortness of breath, and tachycardia
• B. Fever, nausea, and vomiting
• C. Cough, cyanosis, and fatigue
• D. Abdominal pain and bradycardia

Correct answer: A

Rationale: The correct answer is A: Chest pain, shortness of breath, and tachycardia. These are classic early signs of a pulmonary embolism. Chest pain may be sudden and sharp, worsened by deep breathing or coughing. Shortness of breath can be sudden and severe. Tachycardia (rapid heart rate) is another common symptom. Choices B, C, and D are incorrect as they do not represent typical early signs of a pulmonary embolism.

5. When managing a physically assaultive client, the nurse's INITIAL priority is to

• A. Restrict the client to the room
• B. Place the client under one-to-one supervision
• C. Restore the client's self-control and prevent further loss of control
• D. Clear the immediate area of other clients to prevent harm

Correct answer: C

Rationale: When dealing with a physically assaultive client, the initial priority is to focus on restoring the client's self-control and preventing further escalation. Restricting the client to the room (choice A) may escalate the situation and is not the initial priority. Placing the client under one-to-one supervision (choice B) is important but comes after ensuring the client's self-control. Clearing the immediate area of other clients (choice D) is essential for safety but is not the initial priority when compared to restoring the client's self-control.

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