Nursing Elites

1. The nurse is caring for a client with a suspected stroke. Which assessment finding is most indicative of a stroke?

• A. Chest pain
• B. Sudden confusion and difficulty speaking
• C. Gradual onset of weakness in the legs
• D. Nausea and vomiting

Correct answer: B

Rationale: The correct answer is B: Sudden confusion and difficulty speaking. These are classic signs of a stroke, indicating a neurological deficit that requires urgent medical attention. Choices A, C, and D are less indicative of a stroke. Chest pain is more commonly associated with cardiac issues, gradual onset of weakness in the legs could be related to other conditions like peripheral neuropathy, and nausea/vomiting may suggest gastrointestinal problems rather than a stroke.

2. A client who was discharged 8 months ago with cirrhosis and ascites is admitted with anorexia and recent hemoptysis. The client is drowsy but responds to verbal stimuli. The nurse programs a blood pressure monitor to take readings every 15 minutes. Which assessment should the nurse implement first?

• A. Evaluate distal capillary refill for delayed perfusion
• B. Check the extremities for bruising and petechiae
• C. Examine the peritibial regions for pitting edema
• D. Palpate the abdomen for tenderness and rigidity

Correct answer: D

Rationale: In a client with a history of cirrhosis and ascites presenting with anorexia and recent hemoptysis, palpating the abdomen for tenderness and rigidity is crucial as it helps in identifying signs of complications related to these conditions. Assessing for abdominal tenderness and rigidity can provide valuable information about the presence of internal bleeding, ascites complications, or liver enlargement. Evaluating distal capillary refill, checking for bruising and petechiae, or examining peritibial regions for pitting edema are important assessments but are not the priority in this case, given the client's history and current symptoms.

3. The nurse is caring for a client with myasthenia gravis. Which symptom is most important for the nurse to report to the healthcare provider?

• A. Diplopia (double vision)
• B. Difficulty swallowing
• C. Weakness in the legs
• D. Fatigue

Correct answer: B

Rationale: In a client with myasthenia gravis, difficulty swallowing is the most crucial symptom to report to the healthcare provider. This is because it can lead to aspiration, a severe complication in these clients. Diplopia (double vision) and weakness in the legs are common symptoms of myasthenia gravis but are not as immediately dangerous as difficulty swallowing. Fatigue is also a common symptom in myasthenia gravis but does not pose the same risk of aspiration as difficulty swallowing.

4. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy at 2 liters per minute via a nasal cannula. Which assessment finding indicates a potential complication of oxygen therapy?

• A. Increased respiratory rate
• B. Decreased level of consciousness
• C. Improved oxygen saturation
• D. Complaints of dry mouth

Correct answer: B

Rationale: In clients with COPD, oxygen therapy can lead to a decrease in the respiratory drive caused by the removal of the hypoxic drive. This can result in carbon dioxide retention, leading to a decreased level of consciousness. Options A, C, and D are incorrect because an increased respiratory rate is typically a sign of hypoxia, improved oxygen saturation is a positive response to oxygen therapy, and complaints of dry mouth are not directly related to oxygen therapy complications in this scenario.

5. A 55-year-old client with symptoms of osteoarthritis asks which form of exercise would be most beneficial. What is the best response by the nurse?

• A. Walking.
• B. Running.
• C. Swimming.
• D. Weight lifting.

Correct answer: C

Rationale: The correct answer is C: 'Swimming.' Swimming is a low-impact exercise that helps maintain joint mobility and reduce pain in clients with osteoarthritis. Unlike running or weight lifting, swimming is gentle on the joints, making it an ideal choice for individuals with osteoarthritis. Walking can be beneficial too, but swimming is often preferred due to its low-impact nature. Running and weight lifting may exacerbate joint pain and should be avoided by individuals with osteoarthritis.

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