Nursing Elites

1. Infection or inflammation of small sacs that protrude from the lumen of the colon is known as:

• A. Diverticulosis
• B. Diverticulitis
• C. Cholelithiasis
• D. Cholecystitis

Correct answer: B

Rationale: Diverticulitis refers to the infection or inflammation of diverticula in the colon. Choice A, Diverticulosis, is the condition of having diverticula without inflammation. Choices C and D, Cholelithiasis and Cholecystitis, are related to the gallbladder and not the colon, making them incorrect in this context.

2. The nurse is caring for clients on a medical floor. Which client will the nurse assess first?

• A. The client with an abdominal aortic aneurysm who is constipated
• B. The client on bed rest who ambulated to the bathroom
• C. The client with essential hypertension who has epistaxis and a headache
• D. The client with arterial occlusive disease who has a decreased pedal pulse

Correct answer: C

Rationale: The correct answer is C because epistaxis and headache in a client with hypertension are signs of a hypertensive crisis that necessitate immediate intervention. Choice A is incorrect as constipation in a client with an abdominal aortic aneurysm, while important, does not indicate an immediate crisis. Choice B is incorrect as a client on bed rest ambulating to the bathroom is a positive sign. Choice D is incorrect because a decreased pedal pulse in arterial occlusive disease should be addressed promptly, but it does not indicate an acute emergency like a hypertensive crisis.

3. The nurse enters a client’s room and the client is demanding release from the hospital. The nurse reviews the client’s record and noted that the client was admitted 2 days ago for treatment of an anxiety disorder, and the admission was voluntary. Which intervention should the nurse initiate first?

• A. Telephone the client’s family and have them persuade the client to stay
• B. Have the client read and sign all the appropriate self-discharge papers
• C. Explain to the client that he cannot leave because he asked for treatment
• D. Notify the client’s healthcare provider of the client’s stated intent to leave the hospital

Correct answer: D

Rationale: The correct intervention for the nurse to initiate first is to notify the client’s healthcare provider of the client’s stated intent to leave the hospital. This action is crucial as it ensures that the client’s care and safety are appropriately managed. Option A is not the best choice as involving the family to persuade the client may not address the client's underlying concerns. Option B is incorrect because having the client sign self-discharge papers without further assessment is not appropriate. Option C is also incorrect as the client's request for treatment does not prevent them from leaving if they are deemed competent to make that decision.

4. What is the primary goal of care for a client diagnosed with sickle cell anemia?

• A. The client will call the healthcare provider if feeling ill.
• B. The client will be compliant with the medical regimen.
• C. The client will live as normal a life as possible.
• D. The client will verbalize understanding of treatments.

Correct answer: C

Rationale: The correct answer is C: 'The client will live as normal a life as possible.' For a client with sickle cell anemia, the primary goal of care is to promote a good quality of life by managing symptoms, preventing crises, and enhancing overall well-being. Option A is incorrect as it focuses on a specific action rather than the overall goal of care. Option B is important but not the primary goal; compliance is a means to achieve better health outcomes. Option D is also important but does not address the holistic approach of helping the client maintain a normal lifestyle despite their condition.

5. The nurse is caring for a client diagnosed with rule-out nephritic syndrome. Which intervention should be included in the plan of care?

• A. Monitor the urine for bright-red bleeding
• B. Evaluate the calorie count of the 500-mg protein diet
• C. Assess the client’s sacrum for dependent edema
• D. Monitor for a high serum albumin level

Correct answer: C

Rationale: Assessing the client’s sacrum for dependent edema is crucial in the care plan for nephritic syndrome as it is common due to protein loss. Dependent edema occurs as a result of decreased oncotic pressure from protein loss in the urine. Monitoring urine for bright-red bleeding (choice A) is more relevant to conditions like glomerulonephritis. Evaluating calorie count or protein intake (choice B) is important for other conditions but not specifically for nephritic syndrome. Monitoring for a high serum albumin level (choice D) is not typically part of the immediate care plan for nephritic syndrome.

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