Nursing Elites

1. In preparing a care plan for a client admitted with a diagnosis of Guillain-Barre syndrome, which nursing problem has the highest priority?

• A. Ineffective coping related to uncertainty of disease progression
• B. Imbalanced nutrition: less than body requirements related to impaired swallowing reflex
• C. Ineffective breathing pattern related to ascending paralysis
• D. Impaired physical mobility related to asymmetrical descending paralysis

Correct answer: C

Rationale: Ineffective breathing pattern is the highest priority nursing problem for a client with Guillain-Barre syndrome due to the potential risk of respiratory failure. As the paralysis ascends, it can affect the muscles needed for breathing, leading to respiratory compromise. Addressing this problem promptly is crucial to prevent respiratory distress and failure. Choices A, B, and D are also important nursing problems in Guillain-Barre syndrome, but ensuring effective breathing takes precedence over coping, nutrition, and mobility due to the immediate threat it poses to the client's life.

2. A client with a prescription for “do not resuscitate” (DNR) begins to manifest signs of impending death. After notifying the family of the client’s status, what priority action should the nurse implement?

• A. Assess the client’s need for pain medication
• B. Document the impending signs of death
• C. Inform the nurse manager of the client’s status
• D. Communicate the client’s status to the chaplain

Correct answer: A

Rationale: Assessing the client’s need for pain medication is the priority action as it ensures comfort at the end of life. Pain management is crucial in providing comfort and dignity to clients during their final moments. Documenting impending signs of death (choice B) is important but not the immediate priority over addressing the client's comfort. Updating the nurse manager (choice C) and informing the chaplain (choice D) can follow once the client's immediate needs are met.

3. A male client with schizophrenia tells the nurse that the hospital has installed cameras that watch him and listening devices that record what everyone says. Which nursing problem should the nurse document for this client?

• A. Noncompliance with medication related to thought broadcasting
• B. Situational self-esteem disturbance secondary to schizophrenia
• C. Disturbed sensory perception related to auditory hallucinations
• D. Impaired environmental interpretation related to paranoid delusions

Correct answer: D

Rationale: The correct answer is D: Impaired environmental interpretation related to paranoid delusions. The client's belief about cameras watching and recording him is a manifestation of paranoid delusions, indicating a misinterpretation of the environment. Choice A is incorrect because thought broadcasting is not directly related to the client's belief about surveillance equipment. Choice B is incorrect as self-esteem disturbance is not the primary issue presented. Choice C is also incorrect as the client is not experiencing auditory hallucinations but rather paranoid delusions about surveillance.

4. A client with rheumatoid arthritis reports a new onset of increasing fatigue. What intervention should the nurse implement first?

• A. Assist the client in conserving energy during daily activities
• B. Explain to the client that this could be a side effect of the medication
• C. Assess the client for pallor
• D. Encourage the client to maintain a balanced diet and hydration

Correct answer: C

Rationale: The correct first intervention for a client with rheumatoid arthritis reporting increasing fatigue is to assess the client for pallor. Fatigue can be a sign of anemia or other complications; assessing for pallor can help determine if anemia is the cause. Option A is incorrect as it does not address the underlying cause of fatigue. Option B assumes the cause without further assessment. Option D is important for overall health but assessing for pallor takes precedence to identify immediate issues related to fatigue.

5. Why is it important to initiate nursing interventions that promote good nutrition, rest, exercise, and stress reduction for clients diagnosed with an HIV infection?

• A. Prevent the spread of infection to others
• B. Improve the function of the immune system
• C. Increase the ability to carry out activities of daily living
• D. Promote a feeling of general well-being

Correct answer: B

Rationale: The correct answer is B: 'Improve the function of the immune system.' Initiating interventions focusing on good nutrition, rest, exercise, and stress reduction aims to enhance the immune system function in clients with HIV infection. For individuals with HIV, maintaining a strong immune system is crucial in fighting the virus and preventing opportunistic infections. Choices A, C, and D are important aspects of care but are secondary to the primary goal of boosting the immune system to combat the effects of the HIV virus.

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