Nursing Elites

1. The nurse is assessing a client with hyperkalemia. Which finding is consistent with this electrolyte imbalance?

• A. Muscle weakness
• B. Decreased deep tendon reflexes
• C. Constipation
• D. Hypotension

Correct answer: A

Rationale: Muscle weakness is a common finding in clients with hyperkalemia. Hyperkalemia can lead to muscle weakness due to the effect of high potassium levels on muscle function. Decreased deep tendon reflexes (Choice B) are not typically associated with hyperkalemia; instead, hyperreflexia or increased reflexes may be observed. Constipation (Choice C) is not a common symptom of hyperkalemia. Hypotension (Choice D) is also not a typical finding in hyperkalemia; instead, hypertension or normal blood pressure may be present.

2. A client with cirrhosis is experiencing pruritus. Which intervention should the nurse include in the care plan?

• A. Administer antihistamines as prescribed
• B. Apply alcohol-based lotions to the skin
• C. Encourage frequent baths with hot water
• D. Limit fluid intake

Correct answer: A

Rationale: The correct answer is A: Administer antihistamines as prescribed. Pruritus, or itching, is a common symptom in clients with cirrhosis. Antihistamines can help relieve itching by blocking the effects of histamine. Applying alcohol-based lotions (choice B) can further dry out the skin and exacerbate itching. Encouraging frequent baths with hot water (choice C) can also worsen pruritus by stripping the skin of natural oils. Limiting fluid intake (choice D) is not directly related to managing pruritus in cirrhosis.

3. A client comes to the antepartal clinic and tells the nurse that she is 6 weeks pregnant. Which sign is she most likely to report?

• A. Decreased sexual libido
• B. Amenorrhea
• C. Quickening
• D. Nocturia

Correct answer: B

Rationale: Amenorrhea is the absence of menstrual periods and is a common early sign of pregnancy, typically reported by a client who is 6 weeks pregnant. Decreased sexual libido (Choice A) may or may not be experienced in early pregnancy, but it is not as specific as amenorrhea. Quickening (Choice C) refers to fetal movements felt by the mother, which usually occurs around 18-20 weeks of pregnancy, not at 6 weeks. Nocturia (Choice D) is waking up at night to urinate and is not typically associated with early pregnancy.

4. The nurse is teaching a client with hypertension about lifestyle modifications. Which recommendation is most effective for lowering blood pressure?

• A. Increase intake of red meat
• B. Engage in regular physical activity
• C. Consume a high-sodium diet
• D. Limit fluid intake to 1 liter per day

Correct answer: B

Rationale: Engaging in regular physical activity is a highly effective recommendation for lowering blood pressure and improving overall cardiovascular health. Regular exercise helps to strengthen the heart, improve blood circulation, and manage weight, all of which contribute to reducing blood pressure levels. Choices A, C, and D are incorrect. Increasing intake of red meat can lead to higher saturated fat consumption, which is detrimental to heart health. Consuming a high-sodium diet can exacerbate hypertension by increasing blood pressure. Limiting fluid intake to 1 liter per day may lead to dehydration and is not a recommended approach for managing hypertension.

5. During a manic episode, what is the most appropriate intervention to implement first for a client with bipolar disorder?

• A. Engage the client in a quiet activity
• B. Provide a structured environment with minimal stimulation
• C. Monitor the client continuously
• D. Adjust the lighting and noise levels

Correct answer: B

Rationale: During a manic episode, individuals with bipolar disorder may experience sensory overload and agitation. Providing a structured environment with minimal stimulation is the most appropriate initial intervention as it can help reduce overwhelming sensory input and promote a sense of calm. Engaging the client in a quiet activity (Choice A) may not be effective if the environment is still overstimulating. Continuous monitoring (Choice C) is important but may not be the first intervention needed. Adjusting lighting and noise levels (Choice D) can be helpful but may not address the core issue of sensory overload and agitation during a manic episode.

Similar Questions