Nursing Elites

1. The nurse is caring for a client with status epilepticus. The most important nursing assessment of this client is

• A. Intravenous fluid infusion
• B. Level of consciousness
• C. Pulse and respirations
• D. Extremities for injuries

Correct answer: B

Rationale: In status epilepticus, the most crucial nursing assessment is the level of consciousness. Assessing the client's level of consciousness is vital as prolonged seizures can result in hypoxia, brain damage, and require immediate intervention. Pulse and respirations (choice C) are important assessments, but in status epilepticus, the priority is to monitor the client's neurological status. Checking intravenous fluid infusion (choice A) and extremities for injuries (choice D) are not the primary assessments needed in managing a client experiencing status epilepticus.

2. The nurse is performing a physical assessment on a client with insulin-dependent diabetes mellitus. Which client complaint calls for immediate nursing action?

• A. Diaphoresis and shakiness
• B. Reduced sensation in the lower leg
• C. Intense thirst and hunger
• D. Painful hematoma on thigh

Correct answer: A

Rationale: Diaphoresis and shakiness are classic signs of hypoglycemia in a client with insulin-dependent diabetes mellitus. Hypoglycemia is a medical emergency that requires immediate intervention to prevent further complications. The nurse should address this complaint promptly by providing a fast-acting source of glucose to raise the client's blood sugar levels. Reduced sensation in the lower leg may indicate peripheral neuropathy, which is a common complication of diabetes but does not require immediate action unless there are signs of injury. Intense thirst and hunger are symptoms of hyperglycemia, which also requires intervention but not as urgently as hypoglycemia. A painful hematoma on the thigh may require assessment and management, but it is not as urgent as addressing hypoglycemia.

3. During which phase of the community organizing process are the leaders or groups given training to develop their knowledge, skills, and attitudes in managing their own programs?

• A. Sustenance and strengthening phase
• B. Pre-entry phase
• C. Organizing-building phase
• D. Entry phase

Correct answer: C

Rationale: The correct answer is C, the organizing-building phase. This phase involves providing training to leaders and groups to develop their knowledge, skills, and attitudes in managing their own programs. Choice A, the sustenance and strengthening phase, focuses more on maintaining and enhancing existing programs rather than training. Choice B, the pre-entry phase, occurs before actual organizing and training take place. Choice D, the entry phase, is about initiating the community organizing process, not specifically about training leaders and groups.

4. A client with chronic renal failure is receiving peritoneal dialysis. The nurse should assess the client for which of the following complications?

• A. Hypertension
• B. Hyperglycemia
• C. Hypokalemia
• D. Hypernatremia

Correct answer: B

Rationale: The correct answer is B: Hyperglycemia. In peritoneal dialysis, hyperglycemia can occur due to the glucose content of the dialysate solution. This high glucose concentration can lead to increased blood sugar levels in the client. Option A, Hypertension, is a common complication in chronic renal failure but is not directly related to peritoneal dialysis. Option C, Hypokalemia, is more commonly associated with loop diuretics or inadequate potassium intake. Option D, Hypernatremia, is more often seen in conditions of excessive sodium intake or water loss, rather than in peritoneal dialysis.

5. The nurse is teaching a client about the healthy use of ego defense mechanisms. An appropriate goal for this client would be

• A. Reduce fear and protect self-esteem
• B. Minimize anxiety and delay apprehension
• C. Avoid conflict and leave unpleasant situations
• D. Increase independence and communicate more effectively

Correct answer: A

Rationale: The correct answer is A: 'Reduce fear and protect self-esteem.' When teaching a client about the healthy use of ego defense mechanisms, the goal is to help the individual manage emotions effectively without denying reality. Using defense mechanisms in a healthy way aims to reduce fear and protect self-esteem while still addressing underlying issues. Choices B, C, and D are incorrect because they do not focus on the core principles of using defense mechanisms in a healthy manner. Minimizing anxiety and delaying apprehension, avoiding conflict and leaving unpleasant situations, and increasing independence and communicating more effectively do not directly align with the goal of utilizing ego defense mechanisms in a constructive way.

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