Nursing Elites

1. If a client is suffering from thyroid storm, the PN can expect to find on assessment:

• A. tachycardia and hyperthermia.
• B. bradycardia and hypothermia.
• C. a large goiter.
• D. a calm, quiet client

Correct answer: A

Rationale: In thyroid storm, there is an excess of thyroxine, leading to symptoms such as tachycardia (rapid heart rate) and hyperthermia (increased body temperature). Atrial fibrillation and palpitations are also commonly observed. Choices B and C are more indicative of hypothyroidism, where the thyroid is underactive, leading to bradycardia (slow heart rate), hypothermia (decreased body temperature), and the development of a large goiter. Choice D, a calm, quiet client, is unlikely in a thyroid storm where the individual would typically present with symptoms of agitation and restlessness due to the hypermetabolic state.

2. A client is admitted to the critical care unit after suffering from a massive cerebral vascular accident. The client's vital signs include BP 160/110, HR 42, Cheyne-Stokes respirations. Based on this assessment, the nurse anticipates the client to be in which acid-base balance?

• A. Respiratory acidosis
• B. Respiratory alkalosis
• C. Metabolic acidosis
• D. Metabolic alkalosis

Correct answer: A

Rationale: In this scenario, the client is exhibiting Cheyne-Stokes respirations, which are characterized by periods of deep breathing alternating with apnea. This pattern indicates respiratory insufficiency, resulting in an accumulation of carbon dioxide in the blood. The elevated BP and slow heart rate further support the respiratory insufficiency, leading to respiratory acidosis. Therefore, the correct answer is Respiratory acidosis. Choices B, C, and D are incorrect. Respiratory alkalosis is characterized by decreased carbon dioxide levels in the blood, which is not indicated by the client's presentation. Metabolic acidosis results from conditions such as renal failure or diabetic ketoacidosis and is not the primary imbalance in this case. Metabolic alkalosis is characterized by elevated pH and bicarbonate levels, which are not present in the client's vital signs.

3. The client is cared for by a nurse and calls for the nurse to come to the room, expressing feeling unwell. The client's vital signs are BP: 130/88, HR: 102, RR: 28. What should the nurse do next?

• A. Administer PRN anxiolytic
• B. Administer Antibiotics
• C. Reassure the client that everything is okay and offer food and beverage
• D. Determine the Glasgow Coma Scale

Correct answer: A

Rationale: Correct! The client's vital signs indicate tachycardia and tachypnea, which could be indicative of hypoxia. Administering a PRN anxiolytic would not address the underlying issue and could mask deterioration. Reassuring the client without further assessment or intervention could lead to a delay in appropriate care if there is a serious underlying cause for the symptoms. Determining the Glasgow Coma Scale is not relevant to the client's presenting symptoms of feeling unwell and suspecting something is wrong, coupled with abnormal vital signs.

4. Which of the following injuries, if demonstrated by a client entering the Emergency Department, is the highest priority?

• A. open leg fracture
• B. open head injury
• C. stab wound to the chest
• D. traumatic amputation of a thumb

Correct answer: C

Rationale: A stab wound to the chest might result in lung collapse and mediastinal shift that, if untreated, could lead to death. Treatment of an obstructed airway or a chest wound is a higher priority than hemorrhage. The principle of ABC (airway, breathing, and circulation) prioritizes care decisions. In this scenario, the stab wound to the chest poses the highest risk to the client's life as it can lead to severe complications such as lung collapse and mediastinal shift. Addressing this injury promptly is crucial to prevent further harm or potential fatality. Open leg fracture, open head injury, and traumatic amputation of a thumb, while serious, do not pose an immediate life-threatening risk compared to a stab wound to the chest.

5. When assessing a client in the Emergency Department whose membranes have ruptured, the nurse notes that the fluid is a greenish color. What is the cause of this greenish coloration?

• A. blood
• B. meconium
• C. hydramnios
• D. caput

Correct answer: B

Rationale: The correct answer is B: meconium. Greenish amniotic fluid passed when the fetus is in a cephalic (head) presentation might indicate fetal distress. A fetus in the breech presentation passes meconium due to compression on the intestinal tract. Choice A, blood, is incorrect as blood in the amniotic fluid would present as a different color. Choice C, hydramnios, refers to an excess of amniotic fluid and would not cause the greenish coloration. Choice D, caput, is swelling of a newborn's scalp and is not related to the color of the amniotic fluid.

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