Nursing Elites

1. What is the priority assessment for a patient receiving intravenous morphine?

• A. Assessing the patient's blood pressure.
• B. Monitoring the patient's respiratory rate.
• C. Checking the patient's pain level.
• D. Monitoring the patient's oxygen saturation.

Correct answer: B

Rationale: The correct answer is monitoring the patient's respiratory rate. When a patient receives intravenous morphine, the priority assessment is to monitor the respiratory rate due to the risk of respiratory depression associated with morphine. This assessment helps in detecting and managing any potential respiratory complications promptly. Assessing blood pressure, checking pain level, and monitoring oxygen saturation are important aspects of patient care but are not the priority when considering the specific risk of respiratory depression with intravenous morphine.

2. The healthcare provider assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis?

• A. Hyperaldosteronism causing increased sodium transport ion in renal tubules
• B. Decreased portacaval pressure with greater collateral circulation
• C. Decreased renin-angiotensin response related to increased renal blood flow
• D. Hypoalbuminemia that results in decreased colloidal oncotic pressure

Correct answer: D

Rationale: In clients with cirrhosis, hypoalbuminemia leads to decreased colloidal oncotic pressure. This reduction in oncotic pressure contributes to the development of edema in the feet and legs (pitting edema) and ascites in the abdomen. Hyperaldosteronism (choice A) would lead to sodium retention but is not the primary mechanism behind edema and ascites in cirrhosis. Decreased portacaval pressure with greater collateral circulation (choice B) is not directly related to the pathophysiology of edema and ascites in cirrhosis. Decreased renin-angiotensin response related to increased renal blood flow (choice C) does not play a significant role in the development of edema and ascites in cirrhosis compared to the impact of hypoalbuminemia on colloidal oncotic pressure.

3. What is the primary action of insulin in the body?

• A. To lower blood pressure.
• B. To promote the absorption of glucose into cells.
• C. To increase blood glucose levels.
• D. To decrease blood glucose levels.

Correct answer: B

Rationale: The correct answer is B: To promote the absorption of glucose into cells. Insulin facilitates the uptake of glucose by cells, thereby decreasing blood glucose levels. Choice A is incorrect as insulin does not directly affect blood pressure. Choice C is inaccurate as insulin works to lower, not increase, blood glucose levels. Choice D is incorrect because insulin's primary role is to lower, not increase, blood glucose levels by promoting glucose uptake into cells.

4. A patient with a diagnosis of Cushing's syndrome is likely to exhibit which of the following symptoms?

• A. Hyperpigmentation.
• B. Moon face.
• C. Hypotension.
• D. Hypertension.

Correct answer: B

Rationale: The correct answer is B: Moon face. Cushing's syndrome is characterized by excess cortisol levels, leading to the distinctive round and full face known as moon face. Hyperpigmentation (choice A) may occur due to increased ACTH levels, but it is not a hallmark symptom like moon face. Hypotension (choice C) is less common in Cushing's syndrome as cortisol typically leads to hypertension (choice D) due to its effects on blood pressure regulation.

5. A client with Herpes Zoster (shingles) on the thorax tells the nurse about having difficulty sleeping. What is the probable cause of this problem?

• A. Frequent cough
• B. Pain
• C. Nocturia
• D. Dyspnea

Correct answer: B

Rationale: The correct answer is B: Pain. Pain is a common and significant symptom of Herpes Zoster (shingles) that can result in difficulty sleeping. The pain associated with shingles can be intense and persistent, making it challenging for the client to find a comfortable position to sleep. Nocturia (choice C), which is excessive urination during the night, is not directly related to difficulty sleeping in this context. While both frequent cough (choice A) and dyspnea (choice D) can cause sleep disturbances, in a client with Herpes Zoster on the thorax, pain is the most probable cause of sleep difficulty.

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