Nursing Elites

1. A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma?

• A. Altered consciousness within the first 24 hours after injury
• B. Confusion immediately following the injury
• C. Headache that resolves quickly
• D. Brief loss of consciousness with a lucid interval

Correct answer: A

Rationale: The correct answer is A. Epidural hematoma often presents with a brief loss of consciousness followed by a lucid interval and then a rapid decline in consciousness. Therefore, altered consciousness within the first 24 hours after the injury is indicative of a developing epidural hematoma. Choices B, C, and D are incorrect because confusion immediately following the injury, headache that resolves quickly, and brief loss of consciousness with a lucid interval are not specific signs of epidural hematoma.

2. After years of struggling with weight management, a middle-aged man is evaluated for gastroplasty. He has experienced difficulty managing his diabetes mellitus and hypertension, but he is approved for surgery. Which intervention is most important for the nurse to include in this client’s plan of care?

• A. Monitor for signs of depression
• B. Apply sequential compression stockings
• C. Provide a wide variety of meal choices
• D. Observe for signs of depression

Correct answer: D

Rationale: Observing for signs of depression is crucial in this patient's plan of care as depression can impact his overall recovery and management post-surgery. Depression is common in individuals struggling with weight management, diabetes mellitus, and hypertension. Monitoring for urinary incontinence (Choice A) is not the priority in this case as the patient is undergoing gastroplasty for weight management, not a urinary issue. Applying sequential compression stockings (Choice B) is important for preventing deep vein thrombosis in immobile patients but is not the priority in this scenario. Providing a wide variety of meal choices (Choice C) is not the most crucial intervention at this stage, as post-gastroplasty dietary restrictions are essential for successful weight management.

3. A female client is admitted for a diabetic crisis resulting from inadequate dietary practices. After stabilization, the nurse talks to the client about her prescribed diet. What client characteristic is most important for successful adherence to the diabetic diet?

• A. Understands the importance of timing insulin administration 30 minutes before eating
• B. Frequently includes fruits and vegetables in meals and snacks
• C. Has access to someone who can assist with meal preparation and monitoring
• D. Demonstrates willingness to consistently follow the prescribed diet

Correct answer: D

Rationale: The most crucial characteristic for successful adherence to a diabetic diet is the client's willingness to consistently follow the prescribed diet plan. Option A, understanding insulin timing, is important for treatment but not directly related to dietary adherence. Option B, consuming fruits and vegetables, is a healthy practice but does not ensure adherence to a specific diabetic diet. Option C, having assistance with meal preparation, is beneficial but not as essential as the client's personal commitment to adhering to the diet consistently.

4. A client with myasthenia gravis (MG) is receiving immunosuppressive therapy. Review of recent laboratory test results shows that the client’s serum magnesium level has decreased below the normal range. In addition to contacting the healthcare provider, what nursing action is most important?

• A. Check the visual difficulties
• B. Note the most recent hemoglobin level
• C. Assess for hand and joint pain
• D. Observe rhythm on telemetry monitor

Correct answer: D

Rationale: The correct answer is to observe the rhythm on the telemetry monitor. Decreased magnesium levels can lead to cardiac issues, such as arrhythmias. Monitoring the heart rhythm is crucial in this situation. Checking visual difficulties (choice A) is not directly related to the potential cardiac effects of low magnesium levels. Noting the hemoglobin level (choice B) and assessing for hand and joint pain (choice C) are not the priority when dealing with low magnesium levels and possible cardiac complications.

5. The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. What action should the nurse implement immediately?

• A. Change the dressing using a compression bandage
• B. Test fluid on the dressing for glucose
• C. Document the findings in the electronic medical record
• D. Mark drainage area with a pen and continue to monitor

Correct answer: B

Rationale: The correct action for the nurse to implement immediately upon identifying clear fluid on the surgical dressing post-lumbar surgery is to test the fluid for glucose. Clear fluid could indicate cerebrospinal fluid (CSF) leakage, and testing for glucose can help confirm this. Changing the dressing using a compression bandage (Choice A) without further assessment could lead to complications. Documenting the findings (Choice C) is important but not as immediate as confirming the presence of CSF. Marking the drainage area with a pen and monitoring (Choice D) does not address the need for immediate confirmation of CSF leakage.

Similar Questions