Nursing Elites

1. Which behavior is most likely to result in a breach of client confidentiality?

• A. Discussing a client’s condition during a teaching conference for nursing staff caring for the client
• B. Two nurses planning a client’s care while having lunch in the hospital cafeteria
• C. Nursing students on the same team discussing their assigned client’s conditions
• D. A registered nurse privately sharing personal feelings about a client with another nurse on the team

Correct answer: B

Rationale: The correct answer is B. Discussing client information in a public area, such as a cafeteria, may lead to breaches of confidentiality. Choice A involves discussing a client's condition in a professional setting, which is not likely to result in a breach as it is for educational purposes. Choice C involves nursing students discussing their assigned client's conditions, which is common in a learning environment and not necessarily a breach of confidentiality. Choice D involves a private conversation between healthcare professionals, which is less likely to result in a breach compared to discussing in a public area like a cafeteria where non-authorized individuals may overhear the conversation.

2. A male client with schizophrenia is jerking his neck and smacking his lips. Which finding indicates to the nurse that he is experiencing an irreversible side effect of antipsychotic agents?

• A. Cramping muscular pain
• B. Worming movements of the tongue
• C. Decreased tendon reflexes
• D. Dry oral mucous membranes

Correct answer: B

Rationale: The correct answer is B: Worming movements of the tongue. Worming movements of the tongue, known as tardive dyskinesia, are an irreversible side effect of antipsychotic medications. Tardive dyskinesia is characterized by involuntary, repetitive movements of the tongue, lips, face, trunk, and extremities. Cramping muscular pain (Choice A) is more indicative of dystonia, an extrapyramidal side effect that can be treated effectively with antiparkinsonian medications. Decreased tendon reflexes (Choice C) are not typically associated with irreversible side effects of antipsychotic agents. Dry oral mucous membranes (Choice D) are not specific to irreversible side effects of antipsychotic medications.

3. A client with chronic kidney disease has an arteriovenous (AV) fistula in the left forearm. Which observation by the nurse indicates that the fistula is patent?

• A. Distended, tortuous veins in the left hand
• B. The left radial pulse is 2+ bounding
• C. Auscultation of a thrill on the left forearm
• D. Assessment of a bruit on the left forearm

Correct answer: C

Rationale: Auscultation of a thrill on the left forearm is the correct observation indicating that the AV fistula is patent. A thrill is a palpable vibration or buzzing sensation felt over the fistula, indicating the presence of blood flow. Choices A, B, and D do not directly assess the patency of the fistula. Distended, tortuous veins in the left hand may indicate venous hypertension; a bounding radial pulse could suggest increased blood flow through an artery, but it does not confirm fistula patency; assessment of a bruit indicates turbulent blood flow, but it does not confirm patency.

4. To evaluate the client's therapeutic response to lactulose for signs of hepatic encephalopathy, which assessment should the nurse obtain?

• A. Level of consciousness
• B. Percussion of abdomen
• C. Serum electrolytes
• D. Blood glucose

Correct answer: A

Rationale: The correct answer is A: Level of consciousness. Monitoring the client's level of consciousness is essential in evaluating the effectiveness of lactulose in treating hepatic encephalopathy. Lactulose helps reduce blood ammonia levels by promoting the excretion of ammonia in the stool, thereby improving the client's mental status. Assessing the client's level of consciousness helps determine if the medication is effectively managing hepatic encephalopathy symptoms. Choices B, percussion of the abdomen, and D, blood glucose, are not directly related to evaluating the therapeutic response to lactulose for hepatic encephalopathy. Choice C, serum electrolytes, while important in overall patient care, is not the primary assessment to determine lactulose's effectiveness in treating hepatic encephalopathy.

5. The nurse is preparing to administer an IM injection to a 6-month-old child. Which injection site is best for the nurse to use?

• A. Vastus lateralis
• B. Deltoid
• C. Ventrogluteal
• D. Dorsogluteal

Correct answer: A

Rationale: The vastus lateralis is the preferred site for IM injections in infants due to their limited muscle mass and safety. Infants do not have well-developed muscle mass, making the vastus lateralis the best option for IM injections. The deltoid muscle is typically used for older children and adults. Ventrogluteal and dorsogluteal sites are not recommended for infants due to safety concerns, including the risk of damaging the sciatic nerve. Therefore, the correct choice is the vastus lateralis for IM injections in infants.

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