Nursing Elites

1. A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority?

• A. A client who reports right-sided flank pain and is diaphoretic
• B. A client who has active bleeding from a puncture wound of the left groin area
• C. A client who has a raised red skin rash on his arms, neck, and face
• D. A client who reports shortness of breath and left neck and shoulder pain

Correct answer: D

Rationale: The correct answer is D because shortness of breath with referred pain may indicate a serious condition, such as a cardiac event or pulmonary embolism, making this the highest priority. Option A, flank pain with diaphoresis, could suggest kidney-related issues but is not as immediately life-threatening as compromised breathing. Option B, active bleeding, though serious, can usually be controlled with proper interventions. Option C, a raised red skin rash, may indicate an allergic reaction but is not as urgent as respiratory distress with neck and shoulder pain.

2. A nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which of the following clinical manifestations would the nurse expect to note in the client?

• A. Twitching
• B. Positive Trousseau's sign
• C. Hyperactive bowel sounds
• D. Hyperactive deep tendon reflexes

Correct answer: A

Rationale: The correct answer is A: Twitching. Hypocalcemia often presents with neuromuscular irritability, leading to manifestations such as twitching. Trousseau's sign is actually a positive indicator of hypocalcemia, not negative, making choice B incorrect. Hypoactive bowel sounds are not typically associated with hypocalcemia, making choice C incorrect. Similarly, hypoactive deep tendon reflexes are not a common finding in hypocalcemia, making choice D incorrect.

3. Select the nursing theorist who is accurately paired with the theory or model of nursing that they are credited with.

• A. The Twelve Nursing Problems: Faye Glenn Abdullah
• B. The Nature of Nursing: Imogene King
• C. The Goal Attainment Theory: Virginia Henderson
• D. The Interpersonal Relations Model: Hildegard Peplau

Correct answer: D

Rationale: The correct answer is D. Hildegard Peplau is credited with the Interpersonal Relations Model in nursing. Faye Glenn Abdullah is associated with the Developmental Theory of Nursing. Imogene King developed the Theory of Goal Attainment. Virginia Henderson is known for the Definition of Nursing. Therefore, among the given options, only Hildegard Peplau is correctly paired with the Interpersonal Relations Model.

4. The nurse is planning care for a patient with acute hypernatremia. What should the nurse include in this patient's plan of care? (select one that does not apply)

• A. Reduce IV access
• B. Limit length of visits
• C. Restrict fluids to 1500 mL per day
• D. Conduct frequent neurologic checks

Correct answer: D

Rationale: For a patient with acute hypernatremia, the nurse should include interventions like reducing free water losses, correcting sodium levels slowly, monitoring neurologic status, and ensuring adequate fluid intake. Conducting frequent neurologic checks is essential in assessing the patient's neurological status and detecting any changes promptly. Therefore, this action should not be excluded from the plan of care. Choices A, B, and C are not directly related to managing acute hypernatremia and can be safely excluded from the plan of care. Reducing IV access, limiting length of visits, and restricting fluids to 1500 mL per day are not appropriate actions for managing acute hypernatremia.

5. Which preventive measure can be employed to decrease the risk of compartment syndrome?

• A. The administration of a potassium-sparing diuretic for heart failure
• B. A bivalve cast for a skeletal fracture
• C. A cerebral diuretic to decrease intracranial pressure after a head injury
• D. A chest tube to restore normal intrathoracic pressure after a pneumothorax

Correct answer: B

Rationale: The correct answer is B. A bivalve cast can help decrease the risk of compartment syndrome by providing space for swelling, thus preventing the build-up of pressure within the muscles. Choices A, C, and D are incorrect because they are not directly related to preventing compartment syndrome. Choice A is more focused on managing heart failure, choice C on reducing intracranial pressure, and choice D on restoring intrathoracic pressure after a pneumothorax, which are not relevant to preventing compartment syndrome.

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