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. 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.

3. Which of the following terms refers to soft tissue injury caused by blunt force?

• A. contusion
• B. strain
• C. sprain
• D. dislocation

Correct answer: A

Rationale: A contusion is a soft tissue injury caused by blunt force. It is an injury that does not break the skin, caused by a blow, and characterized by swelling, discoloration, and pain. The immediate application of cold might limit the development of a contusion. A strain is a muscle pull from overuse, overstretching, or excessive stress. A sprain is caused by a wrenching or twisting motion. A dislocation is a condition where the articular surfaces of the bones forming a joint are no longer in anatomical contact. Therefore, the correct answer is 'contusion' as it specifically relates to soft tissue injury caused by blunt force.

4. A 32-year-old male with a complaint of dizziness has an order for Morphine via IV. What should the nurse do first?

• A. Check the patient's chest x-ray results.
• B. Retake vitals including blood pressure.
• C. Perform a neurological screening on the patient.
• D. Request the physician on-call to assess the patient.

Correct answer: B

Rationale: The correct first action for the nurse to take in this situation is to retake the patient's vitals, including blood pressure. Dizziness can be a sign of hypotension, which may be a contraindication for administering Morphine. Checking the chest x-ray results (Choice A) would not be the priority in this case as addressing the dizziness is more urgent. Performing a neurological screening (Choice C) may be important but not the first step when a patient presents with dizziness and an order for Morphine. Requesting the physician to assess the patient (Choice D) should come after the initial assessment and vitals retake.

5. A physician orders a serum creatinine for a hospitalized client. The nurse should explain to the client and his family that this test:

• A. is normal if the level is 4.0 to 5.5 mg/dl.
• B. can be elevated with increased protein intake.
• C. is a better indicator of renal function than the BUN.
• D. reflects the fluid volume status of a person

Correct answer: C

Rationale: A serum creatinine level should be 0.7 to 1.5 mg/dl, and it does not vary with increased protein intake, so it is a better indicator of renal function than the BUN. Choice A is incorrect as a serum creatinine level of 4.0 to 5.5 mg/dl is not normal. Choice B is incorrect as serum creatinine is not affected by increased protein intake. Choice D is incorrect as serum creatinine primarily reflects renal function, not fluid volume status.

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