Nursing Elites

1. The nurse is caring for a client with cirrhosis of the liver and suspects that the client may be developing hepatic encephalopathy. Which assessment by the nurse suggests that the client is developing this complication?

• A. Asterixis
• B. Hypertension
• C. Kussmaul respirations
• D. Lethargy

Correct answer: A

Rationale: Asterixis, also known as flapping tremors, is a characteristic sign of hepatic encephalopathy. It is a flapping tremor of the hands when the wrists are extended, indicating neurological impairment. Hypertension and Kussmaul respirations are not directly associated with hepatic encephalopathy. Lethargy is a common symptom but not a specific sign that suggests the development of hepatic encephalopathy.

2. What is the drug of choice for herpes simplex virus 1, herpes simplex virus 2, and varicella-zoster virus?

• A. HIV.
• B. HSV 1, HSV 2, and VZV.
• C. CMV
• D. Influenza A viruses.

Correct answer: B

Rationale: Acyclovir (Zovirax) is the drug of choice for herpes simplex virus 1 (HSV-1), herpes simplex virus 2 (HSV-2), and varicella-zoster virus (VZV) infections. It works by inhibiting viral DNA replication. Acyclovir is excreted unchanged in the urine, so caution is needed in renal impairment. Choice A, HIV, is incorrect as acyclovir is not the drug of choice for HIV. Choice C, CMV, is incorrect as acyclovir is not the preferred treatment for cytomegalovirus (CMV) infections. Choice D, Influenza A viruses, is incorrect as acyclovir is not used to treat influenza viruses.

3. A healthcare professional is reviewing a patient's medical record. The record indicates the patient has limited shoulder flexion on the left. Which plane of movement is limited?

• A. Horizontal
• B. Sagittal
• C. Frontal
• D. Vertical

Correct answer: B

Rationale: The correct answer is 'Sagittal.' The sagittal plane divides the body into left and right halves, and movements in this plane involve flexion and extension. In this case, limited shoulder flexion on the left indicates a restriction in the forward and backward movement of the arm, which occurs in the sagittal plane. Choice A, 'Horizontal,' is incorrect as it refers to movements parallel to the ground. Choice C, 'Frontal,' is incorrect as it involves side-to-side movements. Choice D, 'Vertical,' is incorrect as it typically refers to up and down movements.

4. How can light therapy be effective?

• A. Improving weight problems.
• B. Assisting with allergies.
• C. Using in alternative medical treatments.
• D. Working with sleep patterns.

Correct answer: D

Rationale: Light therapy can be effective in treating problems associated with sleep patterns, stress, moods, jaundice in newborns, and seasonal affective disorders. While light therapy may have other potential benefits, such as improving mood or helping with seasonal affective disorders, the main focus and effectiveness of light therapy are commonly linked to regulating sleep patterns. Therefore, the correct answer is 'Working with sleep patterns.' Choices A, B, and C are incorrect as light therapy is not primarily used for overcoming weight problems, helping with allergies, or solely as an alternative medical treatment.

5. The manic client has just interrupted the group session with the counselor for the 4th time, explaining that she already knows this information on 'dealing with others when you are down' and constantly gets up and goes to the front. What should the nurse do at this time?

• A. Engage the client to walk with you to make another pot of coffee
• B. Ask the client to reflect on their behavior to determine if it is appropriate
• C. Ask the group to tell the client how they feel when she interrupts
• D. Instruct the client to perform jumping jacks and count aloud to get rid of some energy

Correct answer: A

Rationale: In this situation, it is important to redirect the client's energy and focus. Engaging the client in a purposeful activity like making another pot of coffee can help distract them from disruptive behavior and provide an outlet for their excess energy. This choice also helps in maintaining a therapeutic environment by involving the client in a constructive task. Asking the client to reflect on their behavior (Choice B) might not be effective during a manic episode as the client may not be in a state to critically analyze their actions. Asking the group to tell the client how they feel (Choice C) can escalate the situation and may not be appropriate in this context. Instructing the client to perform jumping jacks and count aloud (Choice D) may not address the underlying issue of disruptive behavior and may not be suitable for the current situation.

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