Nursing Elites

1. A nurse is preparing a plan of care for a client with DM who has hyperglycemia. The priority nursing diagnosis would be:

• A. High risk for deficient fluid volume
• B. Deficient knowledge: disease process and treatment
• C. Imbalanced nutrition: less than body requirements
• D. Disabled family coping: compromised

Correct answer: A

Rationale: The priority nursing diagnosis for a client with diabetes mellitus (DM) experiencing hyperglycemia would be 'High risk for deficient fluid volume.' Hyperglycemia can lead to osmotic diuresis, causing significant fluid loss and an increased risk of deficient fluid volume. This nursing diagnosis addresses the immediate physiological concern related to fluid balance.\n\nChoice B, 'Deficient knowledge: disease process and treatment,' focuses on the client's understanding of DM, which is important but not the priority when the client is at risk of fluid volume deficit.\n\nChoice C, 'Imbalanced nutrition: less than body requirements,' pertains to inadequate intake of nutrients, which is not the priority concern when fluid volume deficit poses a more immediate threat.\n\nChoice D, 'Disabled family coping: compromised,' addresses a psychosocial aspect and is not the priority over the critical physiological issue of fluid volume deficit in a client with hyperglycemia.

2. What clinical feature distinguishes a hypoglycemic reaction from a ketoacidosis reaction?

• A. Blurred vision.
• B. Diaphoresis.
• C. Nausea.
• D. Weakness.

Correct answer: B

Rationale: Diaphoresis is the correct answer because it is more characteristic of hypoglycemia. Hypoglycemia typically presents with symptoms such as diaphoresis (excessive sweating), palpitations, tremors, and anxiety. On the other hand, ketoacidosis is associated with symptoms such as fruity breath, deep and labored breathing (Kussmaul respirations), nausea, vomiting, and abdominal pain. Blurred vision can occur in both hypoglycemia and ketoacidosis due to metabolic disturbances affecting the eyes. Weakness is a nonspecific symptom that can be present in both conditions, making it less helpful in distinguishing between the two.

3. The healthcare provider is monitoring a client with Cushing's syndrome. Which of the following findings should the healthcare provider report?

• A. Hypotension
• B. Hyperglycemia
• C. Weight loss
• D. Hypokalemia

Correct answer: B

Rationale: In Cushing's syndrome, hyperglycemia is a common finding due to increased cortisol levels leading to insulin resistance. This can have serious implications such as diabetes mellitus and should be promptly reported for appropriate management. Hypotension (choice A) is more commonly associated with Addison's disease, not Cushing's syndrome. Weight gain rather than weight loss (choice C) is typically observed in clients with Cushing's syndrome. While hypokalemia (choice D) can occur in Cushing's syndrome due to excess cortisol affecting potassium levels, it is not as critical as hyperglycemia and may not be the priority for immediate reporting.

4. During the physical examination, Nurse Noah expects to assess which sign in a female client with a serum calcium level of 7.2 mg/dl?

• A. Trousseau's sign
• B. Homans' sign
• C. Hegar's sign
• D. Goodell's sign

Correct answer: A

Rationale: Trousseau's sign is a clinical indicator of hypocalcemia, characterized by carpal spasm when a blood pressure cuff is inflated above systolic pressure and maintained for a few minutes. This occurs due to increased neuromuscular irritability associated with low serum calcium levels. Homans' sign is used to assess for deep vein thrombosis and involves calf pain upon dorsiflexion of the foot. Hegar's sign is a softening of the lower uterine segment seen in pregnancy, while Goodell's sign is softening of the cervix also seen in pregnancy. Therefore, in this scenario, the correct assessment related to hypocalcemia would be Trousseau's sign.

5. A nursing student needs to administer potassium chloride intravenously as prescribed to a client with hypokalemia. The nursing instructor determines that the student is unprepared for this procedure if the student states that which of the following is part of the plan for preparation and administration of the potassium?

• A. Obtaining a controlled IV infusion pump
• B. Monitoring urine output during administration
• C. Diluting an appropriate amount of normal saline
• D. Preparing the medication for bolus administration

Correct answer: D

Rationale: The correct answer is preparing the medication for bolus administration (Choice D). Potassium should never be administered as a bolus because it can cause cardiac arrest. It must always be diluted and given slowly. Obtaining a controlled IV infusion pump (Choice A) is essential for accurate delivery, monitoring urine output during administration (Choice B) helps assess the client's response, and diluting an appropriate amount of normal saline (Choice C) is necessary to prevent irritation and ensure safe administration.

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