Nursing Elites

1. A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider?

• A. The patient is experiencing laryngeal stridor.
• B. The patient complains of generalized fatigue.
• C. The patient has not had a bowel movement for 4 days.
• D. The patient has numbness and tingling of the lips.

Correct answer: A

Rationale: The correct answer is A - 'The patient is experiencing laryngeal stridor.' Hypocalcemia can cause laryngeal stridor, which may lead to respiratory arrest. Rapid action is required to correct the patient’s calcium level to prevent a life-threatening situation. Choices B, C, and D are also symptoms of hypocalcemia, but laryngeal stridor takes precedence due to its potential to quickly progress to a critical condition.

2. A female client's significant other has been at her bedside providing reassurances and support for the past 3 days, as desired by the client. The client's estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement?

• A. Obtain a court order to enforce visitation rights for the significant other
• B. Request a consultation with the ethics committee for resolution of the situation
• C. Suggest involving security to manage the conflict between the husband and the significant other
• D. Discuss with the client the importance of setting clear boundaries with both individuals

Correct answer: B

Rationale: In this situation, where there is a conflict between the client's significant other and estranged husband, the most appropriate intervention is to request a consultation with the ethics committee for resolution. This ensures that an impartial body can assess the situation, consider the rights and preferences of all parties involved, and provide guidance on how to proceed in a fair and ethical manner. Obtaining a court order (Choice A) may be a legal option but should be considered after exhausting other conflict resolution methods. Involving security (Choice C) may escalate the situation and should only be considered if there is a risk of harm. Discussing boundaries with the client (Choice D) is important but may not immediately address the current conflict between the significant other and the husband.

3. The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse?

• A. Blood pressure is 90/40 mm Hg.
• B. Urine output is 30 mL over the last hour.
• C. Oral fluid intake is 100 mL over the last 8 hours.
• D. There is prolonged skin tenting over the sternum.

Correct answer: A

Rationale: The correct answer is A: "Blood pressure is 90/40 mm Hg." A low blood pressure reading of 90/40 mm Hg indicates that the patient may be developing hypovolemic shock due to intravascular fluid loss from the burn injury. This finding is of utmost concern as it suggests systemic hypoperfusion, requiring immediate intervention to prevent complications. Choices B, C, and D also indicate signs of dehydration and the need to increase fluid intake; however, they are not as urgent as addressing the hypotension and potential shock presented in choice A.

4. The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake?

• A. Increase fluids if your mouth feels dry.
• B. More fluids are needed if you feel thirsty.
• C. Drink more fluids in the late evening hours.
• D. If you feel lethargic or confused, you need more to drink.

Correct answer: A

Rationale: The correct answer is A. An alert, older patient can self-assess for signs of dehydration like dry mouth. This instruction is appropriate as it encourages the patient to respond to early signs of dehydration. Choice B is incorrect because the thirst mechanism decreases with age and feeling thirsty may not accurately indicate the need for fluids. Choice C is incorrect as many older patients prefer to limit evening fluid intake to enhance sleep quality. Choice D is incorrect because an older adult who is lethargic or confused may not be able to accurately assess their need for fluids.

5. An adult who has recurrent episodes of depression tells the nurse that the prescribed antidepressant needs to be discontinued because the client is feeling better after taking the medication for the past couple of weeks and does not like the side effects. Which response is best for the nurse to provide?

• A. Remind the client that feeling better is the therapeutic effect of the medication.
• B. Inform the client that gradual tapering must be used to discontinue the medication.
• C. Tell the client to discuss the medication side effects with the healthcare provider.
• D. Tell the client that the medication side effects will most likely diminish over time.

Correct answer: B

Rationale: The best response for the nurse is to inform the client that gradual tapering must be used to discontinue the medication. Abrupt cessation of antidepressants can lead to withdrawal symptoms or a recurrence of depressive symptoms. Choice A is not the best response as it does not address the need for a proper discontinuation plan. Choice C is not the best response as it focuses solely on the side effects and does not address the discontinuation process. Choice D is not the best response because while side effects may diminish over time, the focus here should be on the safe discontinuation of the medication to prevent adverse effects.

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