Nursing Elites

1. A teenage client is admitted to the hospital because of acetaminophen (Tylenol) overdose. Overdoses of acetaminophen can precipitate life-threatening abnormalities in which of the following organs?

• A. lungs
• B. liver
• C. kidneys
• D. adrenal glands

Correct answer: B

Rationale: Acetaminophen is extensively metabolized in the liver. An overdose of acetaminophen can lead to severe liver damage and even liver failure, which can be life-threatening. Choices A, C, and D are incorrect because although prolonged use of acetaminophen may lead to an increased risk of renal dysfunction, a single overdose does not typically cause life-threatening abnormalities in the lungs, kidneys, or adrenal glands.

2. During data collection of a client with suspected carpal tunnel syndrome, a nurse plans to perform the Phalen test. The nurse should ask the client to perform which activity?

• A. Dorsiflex the foot
• B. Plantarflex the foot
• C. Hold the hands back to back while flexing the wrists 90 degrees for 60 seconds
• D. Hyperextend the fingers with the palmar surfaces of the hands touching, holding the position for 60 seconds

Correct answer: C

Rationale: In the Phalen test, the nurse asks the client to hold the hands back to back while flexing the wrists 90 degrees. This position puts pressure on the median nerve, eliciting symptoms in carpal tunnel syndrome. Dorsiflexing or plantarflexing the foot and hyperextending the fingers are not associated with testing for carpal tunnel syndrome. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand.

3. A rubella titer is performed on a pregnant client, and the results indicate a titer of less than 1:8. The nurse provides the client with which information?

• A. She must have been exposed to the rubella virus at some point in her life.
• B. The test will need to be repeated during the pregnancy.
• C. She has not developed immunity to the rubella virus.
• D. The test results are normal.

Correct answer: B

Rationale: A rubella titer of less than 1:8 indicates that the client is not immune to rubella. In such cases, retesting will be necessary during the pregnancy. If the client is found to be non-immune, rubella immunization is required post-delivery. Therefore, choices A, C, and D are incorrect. Choice A suggests exposure, which cannot be confirmed by the titer result. Choice C wrongly implies that the client has not developed immunity, which is not accurate. Choice D is incorrect as the titer result is not within the normal immune range.

4. A middle-aged woman tells the nurse that she has been experiencing irregular menses for the past six months. The nurse should assess the woman for other symptoms of:

• A. climacteric
• B. menopause
• C. perimenopause
• D. postmenopause

Correct answer: C

Rationale: Perimenopause refers to a period during which hormonal changes occur gradually, ovarian function diminishes, and menses become irregular. Perimenopause typically lasts around five years. Climacteric is a term that describes the period when physiologic changes result in the cessation of a woman's reproductive ability and decreased sexual activity. This term applies to both genders. Menopause is the time when menstruation permanently stops. Postmenopause refers to the period after menopausal changes are complete. In this scenario, the woman's irregular menses indicate she is likely in the perimenopausal stage, experiencing hormonal fluctuations and changes.

5. During a home visit, the LPN finds a client taking Amiodarone. Which statement by the client indicates an understanding of potential drug side effects?

• A. "It is normal if I have numbing or tingling in my feet."?
• B. "I need to make sure I wear sunblock when going outdoors."?
• C. "I need to take supplemental vitamin B12."?
• D. "I should avoid eating leafy vegetables."?

Correct answer: B

Rationale: The correct answer is B. Amiodarone can cause increased photosensitivity, making it essential for the client to wear sunblock when exposed to sunlight. Choice A is incorrect because numbing or tingling in the feet is not a common side effect of Amiodarone. Choice C is unrelated as the drug does not typically require supplemental vitamin B12. Choice D is also incorrect as there is no need to avoid leafy vegetables specifically due to Amiodarone.

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