Nursing Elites

1. The client is admitted with a period of unobserved loss of consciousness and now has an EEG scheduled this morning. What should the nurse implement?

• A. Keep NPO and hold medication.
• B. Hold sedatives, but allow the client to have breakfast and give other medicines.
• C. Administer medications, but hold anticonvulsants.
• D. Give additional fluids and some caffeine prior to the test.

Correct answer: C

Rationale: Prior to an EEG, it is essential for the client to eat to prevent a drop in blood sugar levels. The nurse should hold sedatives but allow the client to have breakfast and administer other necessary medications. Holding sedatives is crucial to ensure accurate EEG results, while providing breakfast helps maintain stable blood sugar levels. Administering other medications, excluding sedatives, is important for the client's overall care. Choices A, C, and D are incorrect because keeping the client NPO and holding medications, administering medications but holding anticonvulsants, and giving additional fluids and caffeine are not appropriate actions before an EEG.

2. The nurse is teaching a community health class for cancer prevention and screening. Which individual has the highest risk for colon cancer?

• A. Client with irritable bowel syndrome
• B. Family history of colon polyps
• C. Client with cirrhosis of the liver
• D. History of colon surgery

Correct answer: B

Rationale: A family history of colon polyps and/or colon cancer is a significant risk factor for developing colon cancer. Individuals with a family history are more likely to develop colon cancer due to genetic predisposition. While other factors like irritable bowel syndrome, cirrhosis of the liver, and history of colon surgery may contribute to an increased risk of colon cancer, having a family history of colon polyps is the highest risk factor. Irritable bowel syndrome does not directly increase the risk of colon cancer. Cirrhosis of the liver is associated with liver cancer rather than colon cancer. A history of colon surgery may reduce the risk of colon cancer in some cases by removing precancerous polyps.

3. The client is scheduled for surgical repair of a detached retina. What is the most likely preoperative nursing diagnosis for this client?

• A. Anxiety related to loss of vision and potential failure to regain vision.
• B. Deficient knowledge (preoperative and postoperative activities) related to lack of information.
• C. Acute pain related to tissue injury and decreased circulation to the eye.
• D. Risk for infection related to the eye injury.

Correct answer: A

Rationale: The correct preoperative nursing diagnosis for a client scheduled for surgical repair of a detached retina is 'Anxiety related to loss of vision and potential failure to regain vision.' A client facing the threat of permanent blindness due to a detached retina is likely to experience anxiety. Addressing this anxiety is crucial before providing education, as severe anxiety can hinder the client's ability to absorb new information. The nurse should offer emotional support, encourage the client to express concerns, and clarify any misconceptions. Acute pain is not a typical symptom of a detached retina, and the risk of infection preoperatively is minimal, making choices C and D less relevant in this scenario.

4. What are the side effects of first-generation over-the-counter (OTC) antihistamines like diphenhydramine (Benadryl) and hydroxyzine (Atarax) in infants and children?

• A. Reye's syndrome.
• B. cholinergic effects.
• C. paradoxical CNS stimulation.
• D. nausea and diarrhea.

Correct answer: C

Rationale: The correct answer is paradoxical CNS stimulation. First-generation OTC antihistamines, such as diphenhydramine and hydroxyzine, can lead to paradoxical CNS stimulation in infants and children. This phenomenon is characterized by symptoms like excitement, euphoria, restlessness, and confusion, rather than the expected sedative effect. Due to this unexpected response, these antihistamines are used less frequently in pediatric populations. Reye's syndrome is a rare systemic response to a virus and is not a side effect of antihistamines. First-generation OTC antihistamines do not typically exhibit cholinergic effects. Nausea and diarrhea are uncommon side effects of these antihistamines and are less commonly observed than paradoxical CNS stimulation.

5. The client is undergoing an induction for fetal demise at 34 weeks. Immediately after delivery, the mother asks to see the infant. What is the nurse's best response?

• A. Bring the swaddled fetus to the mother
• B. Explain that the cause of death must be determined before she can see the baby
• C. Ask her if she is sure she wants to see the baby
• D. Tell her it would be better to wait until she is in her room before she sees the baby

Correct answer: A

Rationale: The nurse should bring the swaddled fetus to the mother as the best response. Allowing the mother to see the infant immediately after delivery is crucial for her grieving process. It provides her with the opportunity to bond, say goodbye, and start the grieving process. Choice B is incorrect because delaying the mother's request to see the baby can hinder her grieving process and prolong her suffering. Choice C is inappropriate as it questions the mother's decision at a sensitive time, potentially causing distress. Choice D is also not the best response as it suggests waiting, which may not be in the mother's best interest at that moment, as she needs immediate support and closure.

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