Nursing Elites

1. A nurse is educating a client with peripheral artery disease (PAD). Which statement made by the client indicates a need for further teaching?

• A. I should avoid walking for long periods to prevent leg pain.
• B. I should inspect my feet daily for any sores or wounds.
• C. I should wear compression stockings to improve circulation.
• D. I should avoid smoking to prevent further damage to my arteries.

Correct answer: A

Rationale: The correct answer is A. Walking is crucial in improving circulation in peripheral artery disease; therefore, the client should not avoid walking for long periods. Choices B, C, and D are correct statements for a client with PAD. Inspecting feet daily helps in early detection of sores or wounds, wearing compression stockings improves circulation, and avoiding smoking helps prevent further damage to arteries in PAD.

2. A patient with a history of hypertension presents with a severe headache, confusion, and visual disturbances. His blood pressure is 220/120 mm Hg. Which of the following is the most likely diagnosis?

• A. Migraine
• B. Cluster headache
• C. Hypertensive emergency
• D. Tension headache

Correct answer: C

Rationale: A patient with a history of hypertension presenting with a severe headache, confusion, and visual disturbances, along with a blood pressure of 220/120 mm Hg, likely has a hypertensive emergency. In this situation, the severely elevated blood pressure can lead to end-organ damage, causing symptoms such as headache and confusion. Migraine and tension headaches are not associated with such high blood pressure levels. Cluster headaches typically do not present with visual disturbances and confusion in the setting of severe hypertension.

3. During an acute asthma exacerbation, what is the priority nursing intervention for a client with asthma?

• A. Administer corticosteroids to reduce airway inflammation.
• B. Position the client in high-Fowler's position.
• C. Administer short-acting beta-agonists (SABAs) as prescribed.
• D. Obtain a peak flow reading to assess the severity of the exacerbation.

Correct answer: C

Rationale: The priority nursing intervention during an acute asthma exacerbation is to administer short-acting beta-agonists (SABAs) as prescribed. SABAs help in quickly relieving bronchospasm and are considered the first-line treatment for acute exacerbations. Administering corticosteroids, positioning the client, and obtaining a peak flow reading are important interventions but come after administering SABAs in the management of acute asthma exacerbation.

4. Following a spinal cord injury suffered in a motor vehicle accident, a 22-year-old male has lost fine motor function of his finger and thumb, but is still able to perform gross motor movements of his hand and arm. Which component of his 'white matter' has most likely been damaged?

• A. The inner layer (archilayer)
• B. The middle layer (paleolayer)
• C. The outer layer (neolayer)
• D. The reticular formation

Correct answer: C

Rationale: The correct answer is C: The outer layer (neolayer). The white matter of the spinal cord consists of three layers: the outer layer (neolayer), the middle layer (paleolayer), and the inner layer (archilayer). Damage to the outer layer (neolayer) is likely to affect fine motor skills, explaining the loss of fine motor function in the finger and thumb while gross motor movements remain intact. Choices A, B, and D are incorrect as they do not correspond to the specific layer of the white matter that is typically associated with fine motor control.

5. A client with Guillain-Barré syndrome is experiencing ascending paralysis. Which of the following interventions should the nurse prioritize?

• A. Monitor for signs of respiratory distress.
• B. Prepare the client for plasmapheresis.
• C. Administer analgesics for pain management.
• D. Initiate passive range-of-motion exercises.

Correct answer: A

Rationale: The correct answer is A: Monitor for signs of respiratory distress. In Guillain-Barré syndrome, ascending paralysis can lead to respiratory muscle involvement, putting the client at risk for respiratory distress and failure. Prioritizing respiratory monitoring is crucial to ensure timely intervention if respiratory compromise occurs. Plasmapheresis (Choice B) may be indicated in some cases to remove harmful antibodies, but the priority in this situation is respiratory support. Administering analgesics (Choice C) for pain management and initiating passive range-of-motion exercises (Choice D) are important aspects of care but are not the priority when the client's respiratory status is at risk.

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