Nursing Elites

1. 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.

2. A 14-month-old had cleft palate surgical repair several days ago. The parents ask the nurse about feedings after discharge. Which lunch is the best example of an appropriate meal?

• A. Hot dog, carrot sticks, gelatin, milk
• B. Soup, blenderized soft foods, ice cream, milk
• C. Peanut butter and jelly sandwich, chips, pudding, milk
• D. Baked chicken, applesauce, cookie, milk

Correct answer: B

Rationale: Choice B, 'Soup, blenderized soft foods, ice cream, milk,' is the correct answer. After cleft palate repair, it is essential to provide soft and blenderized foods to prevent trauma to the surgical site and promote proper healing. Choices A, C, and D contain foods that may be difficult for the child to consume comfortably and safely after a cleft palate surgical repair. A hot dog, carrot sticks, chips, and hard cookies could potentially cause injury or discomfort to the surgical area. Peanut butter and jelly sandwich might be too difficult to swallow or may stick to the surgical site. Baked chicken could be too challenging to chew. Therefore, the best choice for an appropriate meal post cleft palate repair is soft, blenderized foods like soup, along with other soft options like ice cream and milk.

3. A client with a peptic ulcer is scheduled for a vagotomy and pyloroplasty. The nurse explains that the purpose of this surgery is to:

• A. Increase acid secretion
• B. Reduce acid secretion
• C. Promote gastric emptying
• D. Remove the ulcerated area

Correct answer: B

Rationale: The correct answer is B: "Reduce acid secretion." Vagotomy is performed to reduce acid secretion by cutting the vagus nerve, which stimulates acid production. Choices A, C, and D are incorrect. A vagotomy does not increase acid secretion, promote gastric emptying, or remove the ulcerated area. It specifically aims to decrease acid production to help in the healing of peptic ulcers.

4. The RN is planning care at a team meeting for a 2-month-old child in bilateral leg casts for congenital clubfoot. Which of these suggestions by the PN should be considered the priority nursing goal following cast application?

• A. Infant will experience minimal pain
• B. Muscle spasms will be relieved
• C. Mobility will be managed as tolerated
• D. Tissue perfusion will be maintained

Correct answer: D

Rationale: Following cast application for congenital clubfoot in a 2-month-old child, the priority nursing goal should be to maintain tissue perfusion. This is crucial to prevent complications like compartment syndrome and ensure proper healing. While managing pain, relieving muscle spasms, and promoting mobility are important aspects of care, they are secondary to ensuring adequate tissue perfusion in this scenario.

5. Statistics of illnesses are termed as:

• A. Vital statistics
• B. Morbidity
• C. Statistics
• D. Mortality

Correct answer: B

Rationale: The correct answer is B: 'Morbidity.' Morbidity specifically refers to the statistics of illnesses, encompassing the incidence, prevalence, and duration of disease within a population. Choice A, 'Vital statistics,' typically refers to data on births, deaths, marriages, and divorces. Choice C, 'Statistics,' is a broad term encompassing the collection, analysis, interpretation, and presentation of numerical data. Choice D, 'Mortality,' specifically refers to the state of being subject to death or the number of deaths in a given population.

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