Nursing Elites

1. A nurse is planning care for a client in the late stage of amyotrophic lateral sclerosis (ALS). Which nursing diagnosis has the highest priority?

• A. Impaired physical mobility
• B. Ineffective breathing pattern
• C. Impaired skin integrity
• D. Risk for infection

Correct answer: B

Rationale: Ineffective breathing pattern is the highest priority for a client in the late stage of ALS due to the significant risk of respiratory complications. As ALS progresses, the client may experience respiratory muscle weakness, leading to ineffective breathing patterns and potential respiratory failure. Addressing breathing difficulties promptly is crucial to ensure adequate oxygenation and prevent further complications. While impaired physical mobility, impaired skin integrity, and risk for infection are also important concerns in ALS care, they are secondary to addressing the client's breathing difficulties, which take precedence to maintain physiological stability and prevent life-threatening consequences.

2. When administering an intramuscular injection containing 3 ml of a painful medication, which intervention should the nurse implement?

• A. Instill the medication quickly
• B. Insert the needle slowly
• C. Select a large, deep muscle mass
• D. Use a short, small gauge needle

Correct answer: C

Rationale: The correct answer is C: Select a large, deep muscle mass. When administering an intramuscular injection with a painful medication volume of 3 ml, selecting a large and deep muscle mass is crucial. This intervention reduces discomfort for the patient and ensures proper absorption of the medication. Choice A is incorrect because instilling the medication quickly can increase discomfort. Choice B is incorrect as inserting the needle slowly may prolong the discomfort. Choice D is incorrect as using a short, small gauge needle may not be suitable for delivering 3 ml of medication effectively into the muscle.

3. An adult male is admitted to the psychiatric unit from the emergency department because he is in the manic disorder. He has lost 10 pounds in the last two weeks and has not bathed in a week because he has been 'trying to start a new business' and is 'too busy to eat.' He is alert and oriented to time, place and person, but not situation. Which nursing diagnosis has the greatest priority?

• A. Self-care deficit
• B. Disturbed sleep pattern
• C. Disturbed thought processes
• D. Imbalanced nutrition

Correct answer: D

Rationale: Imbalanced nutrition is the most critical nursing diagnosis to address in this scenario. The patient's significant weight loss and neglect of basic needs, such as eating and personal hygiene, indicate a severe imbalance in nutrition. Addressing this issue is crucial to prevent further health deterioration. Self-care deficit, disturbed sleep pattern, and disturbed thought processes are important but secondary concerns compared to the immediate risk posed by imbalanced nutrition. While self-care deficit and disturbed sleep pattern are valid concerns, the patient's weight loss and neglect of basic needs take precedence. Disturbed thought processes are also significant but addressing the imbalanced nutrition is more urgent in this context.

4. A nurse is planning care for a client who is at risk for developing deep vein thrombosis (DVT). Which intervention should the nurse include in this client's plan of care?

• A. Maintain the client on bed rest
• B. Apply warm, moist compresses to the legs
• C. Encourage early ambulation
• D. Massage the legs daily

Correct answer: C

Rationale: The correct intervention for a client at risk for developing deep vein thrombosis (DVT) is to encourage early ambulation. Early ambulation helps prevent DVT by promoting circulation, reducing stasis, and preventing blood clot formation. Maintaining the client on bed rest (Choice A) would increase the risk of DVT due to decreased mobility. Applying warm, moist compresses to the legs (Choice B) can be beneficial for other conditions but does not directly prevent DVT. Massaging the legs daily (Choice D) can dislodge a blood clot, leading to serious complications in a client at risk for DVT.

5. While assessing a client who is experiencing Cheyne-Stokes respirations, the nurse observes periods of apnea. What action should the nurse implement?

• A. Elevate the head of the client's bed
• B. Auscultate the client's breath sounds
• C. Measure the length of the apneic periods
• D. Suction the client's oropharynx

Correct answer: C

Rationale: When a nurse observes periods of apnea in a client experiencing Cheyne-Stokes respirations, measuring the length of the apneic periods is essential. This action helps in determining the severity of Cheyne-Stokes respirations by providing valuable information about the duration of interrupted breathing cycles. Elevating the head of the client's bed (Choice A) may be beneficial in some respiratory conditions but is not the priority in Cheyne-Stokes respirations. Auscultating the client's breath sounds (Choice B) is a general assessment and may not directly address the issue of apnea in Cheyne-Stokes respirations. Suctioning the client's oropharynx (Choice D) is not the initial intervention for managing Cheyne-Stokes respirations unless secretions are obstructing the airway.

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