Nursing Elites

1. A young boy is recently diagnosed with a seizure disorder. Which of the following statements by the boy's mother indicates a need for further teaching by the nurse?

• A. "I should make sure he gets plenty of rest."?
• B. "I should get him a medical alert bracelet."?
• C. "I should lay him on his back during a seizure."?
• D. "I should loosen his clothing during a seizure."?

Correct answer: C

Rationale: The correct answer is "I should lay him on his back during a seizure."? This statement indicates a need for further teaching because a client having a seizure should be turned to the side to prevent aspiration of secretions. Choices A, B, and D are correct. Getting plenty of rest helps in managing seizures, having a medical alert bracelet informs others about the condition in case of emergency, and loosening clothing during a seizure ensures better air circulation and prevents injury. These actions demonstrate adequate understanding of the teaching provided.

2. In a community hospital, a nurse is employed as a staff nurse and is supervised by a nurse manager. The nurse understands that in this position, the term authority most appropriately refers to which description?

• A. Accepting responsibility for the actions of others
• B. The official power to ensure that an organizational decision is enforced
• C. Bearing the legal responsibility for others' performance of tasks
• D. Taking responsibility for what staff members do

Correct answer: B

Rationale: The term authority refers to the official power of an individual to approve or command an action or to ensure that a decision is enforced. In the context of the nurse's position supervised by a nurse manager, having authority means having the official power to ensure that organizational decisions are carried out. Choice A, accepting responsibility for the actions of others, is more related to accountability rather than authority. Choice C, bearing the legal responsibility for others' performance of tasks, is more about legal liability rather than authority. Choice D, taking responsibility for what staff members do, is similar to choice A and is more about accountability rather than having the official power to enforce decisions. Therefore, the correct answer is B as it directly relates to the concept of authority in the context described.

3. A client with cirrhosis of the liver presents with ascites. The physician is to perform a paracentesis. For safety, the nurse should ask the client to:

• A. drink 1000 cc of fluid prior to the procedure to aid in fluid loss.
• B. eat foods low in fat.
• C. empty his bladder prior to the procedure.
• D. assume the prone position.

Correct answer: C

Rationale: When performing a paracentesis, the client must be sitting up to allow the fluid to settle in the lower abdomen. To prevent trauma to the bladder while inserting a needle to aspirate the fluid, the bladder must be empty. Choice A is incorrect as excessive fluid intake can make the procedure more difficult due to increased abdominal distension. Choice B is unrelated to the procedure of paracentesis. Choice D is incorrect as the client should be sitting up, not in the prone position, during the procedure.

4. For which condition might a client's antidiuretic hormone (ADH) level be increased?

• A. diabetes mellitus
• B. diabetes insipidus
• C. hypothyroidism
• D. hyperthyroidism

Correct answer: B

Rationale: The correct answer is diabetes insipidus. In this condition, the client's ADH level is increased. Diabetes insipidus is characterized by the inability of the kidneys to conserve water due to either inadequate secretion of ADH (central diabetes insipidus) or the kidneys' inability to respond to ADH (nephrogenic diabetes insipidus). Choices A, C, and D are incorrect. In diabetes mellitus, ADH levels are typically normal or elevated in response to high blood sugar levels. Hypothyroidism is not directly related to ADH secretion. In hyperthyroidism, ADH levels are usually normal or decreased.

5. Which of the following is an appropriate nursing goal for a client at risk for nutritional problems?

• A. provide oxygen
• B. promote healthy nutritional practices
• C. treat complications of malnutrition
• D. increase weight

Correct answer: B

Rationale: The correct answer is to promote healthy nutritional practices. This goal focuses on preventive measures to address the client's nutritional risk. Providing oxygen (Choice A) is not directly related to addressing nutritional problems. Treating complications of malnutrition (Choice C) involves addressing the consequences rather than preventing or managing the nutritional problems. Increasing weight (Choice D) would only be appropriate if the client is underweight; it does not address the broader aspect of promoting overall healthy nutritional practices.

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