Nursing Elites

1. After assessing an older adult with a suspected cerebrovascular accident (CVA), the nurse documents the client's right upper arm weakness and slurred speech. When the client complains of a severe headache and nausea, and the neurological assessment remains unchanged, which action should the nurse implement first?

• A. Administer an oral analgesic with antiemetic
• B. Collect blood for coagulation times
• C. Send the client for a computed tomography scan of the brain
• D. Obtain a history of medication use, recent surgery, or injury

Correct answer: C

Rationale: In this scenario, the priority action for the nurse is to send the client for a computed tomography (CT) scan of the brain. A CT scan is crucial in assessing acute changes or bleeding that could influence treatment decisions in a suspected cerebrovascular accident (CVA). While addressing symptoms like headache and nausea is important, ruling out acute changes in the brain with a CT scan takes precedence in this situation. Collecting blood for coagulation times may be necessary but is not the initial priority. Obtaining a history of medication use, recent surgery, or injury is also important but not the first action to take when a CVA is suspected.

2. 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.

3. After learning that she has terminal pancreatic cancer, a female client becomes very angry and says to the nurse, 'God has abandoned me. What did I do to deserve this?' Based on this response, the nurse decides to include which nursing problem in the client’s plan of care?

• A. Ineffective coping
• B. Spiritual distress
• C. Acute pain
• D. Complicated grieving

Correct answer: B

Rationale: The client’s expression of feeling abandoned by God indicates spiritual distress, which is a significant issue that needs to be addressed in the plan of care. The individual is questioning their faith and seeking answers in a higher power, which aligns with spiritual distress. Choices A, C, and D are not as directly related to the client's current emotional and spiritual struggle. Ineffective coping may be a consequence of spiritual distress, acute pain is not the primary concern in this scenario, and complicated grieving is premature as the client is still processing the diagnosis and seeking meaning.

4. An 18-year-old gravida 1, at 41-weeks gestation, is undergoing an oxytocin (Pitocin) induction and has an epidural catheter in place for pain control. With each of the last three contractions, the nurse notes a late deceleration. The client is repositioned, and oxygen provided, but the late decelerations continue to occur with each contraction. What action should the nurse take first?

• A. Prepare for immediate cesarean birth
• B. Turn off the oxytocin (Pitocin) infusion
• C. Notify the anesthesiologist that the epidural infusion needs to be disconnected
• D. Apply an internal fetal monitoring device and continue to monitor carefully

Correct answer: B

Rationale: In the scenario described, the nurse notes late decelerations during contractions despite repositioning and oxygen administration. Late decelerations are often associated with uteroplacental insufficiency, which can be exacerbated by increased uterine activity stimulated by oxytocin. The initial action to manage late decelerations is to turn off the oxytocin infusion to reduce uterine stimulation. This step aims to improve fetal oxygenation and prevent further stress on the fetus. Immediate cesarean birth may be necessary if the late decelerations persist or worsen despite discontinuing the oxytocin infusion. Notifying the anesthesiologist to disconnect the epidural infusion or applying an internal fetal monitoring device are not the first-line interventions for managing late decelerations.

5. An older adult resident of a long-term care facility has a 5-year history of hypertension. The client has a headache and rates the pain 5 on a pain scale of 0 to 10. The client’s blood pressure is currently 142/89. Which interventions should the nurse implement? (Select all that apply)

• A. Administer the scheduled daily dose of lisinopril.
• B. Assess the client for postural hypotension.
• C. Notify the healthcare provider immediately.
• D. Provide a PRN dose of acetaminophen for the headache.

Correct answer: A

Rationale: In this scenario, the client's blood pressure of 142/89 is within an acceptable range for someone with a history of hypertension. The client's headache with a pain rating of 5 does not warrant an immediate notification to the healthcare provider. Administering the scheduled dose of lisinopril is appropriate to manage the client's hypertension. Assessing the client for postural hypotension is relevant due to the client's age and hypertension history. Providing a PRN dose of acetaminophen for the headache is not necessary at this point as the pain level is moderate and can be managed with other interventions.

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