Nursing Elites

1. The PN is caring for an older client who was informed about the diagnosis of terminal cancer two days ago. Which intervention would be most helpful for the client's spouse at this time?

• A. Consultation with the case manager and hospital chaplain
• B. Visiting after procedures are done to avoid seeing the client in pain
• C. Participating in the client's care within his/her capabilities and desires
• D. Information about palliative and hospice care services

Correct answer: D

Rationale: Providing information about palliative and hospice care services can help the spouse understand the options for managing the client's symptoms and improving the quality of life. This also provides support and guidance during a difficult time. Consulting with the case manager and hospital chaplain may be beneficial for emotional support but may not address the practical aspects of care. Visiting after procedures are done to avoid seeing the client in pain may not foster open communication and support. While participating in the client's care is important, providing information about palliative and hospice care services is the most helpful intervention in this scenario.

2. The PN is caring for a client with schizophrenia who continues to repeat the last words heard. Which nursing problem should the PN document in the medical record?

• A. Altered thought processes
• B. Impaired social interaction
• C. Risk for self-directed violence
• D. Disturbed thought processes

Correct answer: D

Rationale: The correct answer is D: Disturbed thought processes. Echolalia, the repetition of heard words, is associated with disturbed thought processes, which are commonly seen in schizophrenia. Altered thought processes (Choice A) is a generic term and does not specifically address the behavior of repeating words. Impaired social interaction (Choice B) is not the primary concern when a client repeats the last words heard. Risk for self-directed violence (Choice C) is not directly related to the behavior of repeating words but focuses on the potential harm the client may cause to themselves.

3. The nurse is providing care for a client with type 1 diabetes mellitus who is receiving NPH insulin. The nurse notices that the client's evening glucose levels are consistently above 260 mg/dl. What does this indicate?

• A. States that her feet are constantly cold and feel numb
• B. A wound on the ankle that starts to drain and becomes painful
• C. Consecutive evening serum glucose greater than 260 mg/dl
• D. Reports nausea in the morning but still able to eat breakfast

Correct answer: C

Rationale: High evening glucose levels suggest that the current insulin dosage may be inadequate to control the client's blood sugar levels effectively. This indicates poor glycemic control and the need for a possible adjustment in the insulin regimen. Option A describes symptoms of peripheral neuropathy, which are not directly related to the elevated glucose levels but may be a long-term complication of diabetes. Option B describes a wound infection, which is not directly related to the client's high glucose levels. Option D mentions morning nausea, which could be due to various causes and is not directly related to the high evening glucose levels.

4. The nurse is teaching a pregnant client how to distinguish prelabor contractions from true labor contractions. Which statement about prelabor contractions is accurate?

• A. They are irregular
• B. They are usually felt in the abdomen
• C. They start in the back and radiate to the abdomen
• D. They become more intense during walking

Correct answer: B

Rationale: The correct statement about prelabor contractions (Braxton Hicks contractions) is that they are usually felt in the abdomen. They are irregular in nature and do not intensify with movement. Choice A is incorrect because prelabor contractions are irregular, not regular. Choice C is incorrect as prelabor contractions do not start in the back and radiate to the abdomen. Choice D is incorrect as prelabor contractions do not become more intense during walking.

5. The PN is caring for a laboring client whose last sterile vaginal examination revealed the cervix was 3 cm dilated, 50% effaced, and the presenting part was at 0 station. An hour later, the client tells the PN that she wants to go to the bathroom. Which action is most important for the PN to implement?

• A. Review the fetal heart rate and contraction pattern
• B. Check the perineum for an increase in bloody show
• C. Request a nurse to check the client's cervical dilation
• D. Palpate the client's bladder for distention

Correct answer: C

Rationale: The sudden urge to use the bathroom may indicate that labor is progressing quickly. Checking the cervical dilation will help determine if the client is in the transition phase of labor and if it is appropriate to allow her to get up. Reviewing the fetal heart rate and contraction pattern (Choice A) is important but not the most immediate action in this scenario. Checking the perineum for an increase in bloody show (Choice B) is relevant but not as crucial as assessing cervical dilation. Palpating the client's bladder for distention (Choice D) is not the priority when the client wants to go to the bathroom during labor.

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