Nursing Elites

1. A healthcare professional is collecting data from a client who is experiencing post-traumatic stress disorder (PTSD). Which of the following manifestations should the healthcare professional expect?

• A. Hyperactivity
• B. Hypervigilance
• C. Restlessness
• D. Avoidance of social situations

Correct answer: B

Rationale: Hypervigilance is a common manifestation of PTSD characterized by heightened alertness and fear of danger. This heightened state of awareness can lead to irritability, difficulty concentrating, and sleep disturbances. Choices A, C, and D are incorrect. Hyperactivity is not typically associated with PTSD; restlessness may be present but is not the primary manifestation, and avoidance of social situations is more commonly seen in conditions like social anxiety disorder rather than PTSD.

2. A client has hypoglycemia and is conscious. Which of the following actions should the nurse take?

• A. Administer glucagon IM
• B. Give the client 4 oz of fruit juice
• C. Provide the client with peanut butter
• D. Give the client 1 L of water

Correct answer: B

Rationale: In conscious clients with hypoglycemia, the most appropriate action is to provide a rapidly absorbed carbohydrate source like fruit juice to raise blood glucose levels quickly. Administering glucagon intramuscularly (IM) is usually reserved for unconscious clients or those who are unable to take oral glucose. Providing peanut butter or water would not rapidly address the hypoglycemic state as fruit juice would.

3. A nurse is caring for a client with a pressure ulcer and a serum albumin level of 3 g/dL. What should the nurse do first?

• A. Increase the client's protein intake
• B. Consult with a dietitian to improve the client's nutritional status
• C. Administer a protein supplement
• D. Monitor the client's fluid and electrolyte balance

Correct answer: B

Rationale: Consulting with a dietitian is the priority as it ensures that the client receives a comprehensive nutritional assessment and an individualized plan to address the low serum albumin level and pressure ulcer. Increasing protein intake (choice A) and administering a protein supplement (choice C) may be part of the dietitian's recommendations but should not be done without proper assessment and guidance. Monitoring fluid and electrolyte balance (choice D) is important but not the first step in addressing the client's nutritional needs.

4. A nurse is caring for a client who is experiencing post-traumatic stress disorder (PTSD). Which of the following manifestations should the nurse expect?

• A. Hyperactivity
• B. Hypervigilance
• C. Restlessness
• D. Avoidance of social situations

Correct answer: B

Rationale: The correct answer is B: Hypervigilance. Individuals with PTSD often experience hypervigilance, which involves being overly alert, easily startled, and constantly scanning their environment for potential threats. This heightened state of awareness is a common response to the trauma experienced. Choices A, C, and D are incorrect. Hyperactivity is not typically a primary manifestation of PTSD; restlessness may occur but is not as characteristic as hypervigilance, and although avoidance of social situations can be a symptom of PTSD, hypervigilance is more directly associated with the disorder.

5. A nurse is receiving report on four clients. Which of the following clients should the nurse plan to see first?

• A. A client who is NPO and has dry mucous membranes
• B. A client with rotavirus who has been vomiting
• C. A client who has a urinary catheter and cloudy urine
• D. A client who has pneumonia and a new onset of confusion

Correct answer: D

Rationale: The correct answer is D because a client with pneumonia and a new onset of confusion needs immediate evaluation for changes in neurological status. This could indicate a decline in respiratory status or potential complications such as hypoxia or sepsis. Option A, a client who is NPO and has dry mucous membranes, may need intervention but does not indicate an acute change in condition. Option B, a client with rotavirus who has been vomiting, requires assessment and intervention but does not pose an immediate threat to life. Option C, a client with a urinary catheter and cloudy urine, may indicate a urinary tract infection but does not require immediate attention compared to the client with new onset confusion and pneumonia.

Similar Questions