Nursing Elites

1. Which of the following is a key symptom of myocardial infarction (MI)?

• A. Chest pain.
• B. Shortness of breath.
• C. Nausea.
• D. Fatigue.

Correct answer: A

Rationale: The correct answer is A: Chest pain. Chest pain is a hallmark symptom of myocardial infarction (MI) due to inadequate blood flow to the heart muscle. This pain can be severe, crushing, or squeezing, and may radiate to the left arm, jaw, or back. Shortness of breath (choice B), nausea (choice C), and fatigue (choice D) can accompany MI but are not as specific or characteristic as chest pain in diagnosing this condition. Therefore, chest pain is the primary symptom to recognize for suspected MI.

2. The best indicator that the client has learned how to give an insulin self-injection correctly is when the client can:

• A. Perform the procedure safely and correctly.
• B. Critique the nurse's performance of the procedure.
• C. Explain all steps of the procedure correctly.
• D. Correctly answer a post-test about the procedure.

Correct answer: A

Rationale: The best indicator of learning is the ability to perform the procedure safely and correctly, demonstrating skill acquisition. Choice A is correct because the client's ability to perform the insulin self-injection safely and correctly shows practical understanding and application of the skill. Choice B is incorrect because critiquing the nurse's performance does not necessarily demonstrate the client's ability to carry out the procedure themselves. Choice C is incorrect as merely explaining the steps verbally does not confirm the client's practical execution of the task. Choice D is also incorrect as answering a post-test does not directly assess the client's ability to physically perform the insulin self-injection.

3. The client who has a history of Parkinson's disease for the past 5 years is being assessed by the nurse. What symptoms would this client most likely exhibit?

• A. Loss of short-term memory, facial tics, and grimaces, and constant writhing movements.
• B. Shuffling gait, masklike facial expression, and tremors of the head.
• C. Extreme muscular weakness, easy fatigability, and ptosis.
• D. Numbness of the extremities, loss of balance, and visual disturbances.

Correct answer: B

Rationale: Parkinson's Disease, a common neurologic progressive disorder in older clients, is characterized by symptoms such as shuffling gait, masklike facial expression, and tremors of the head and hands. Choice A is incorrect as symptoms like loss of short-term memory, facial tics, and constant writhing movements are not typically associated with Parkinson's disease. Choice C is incorrect as extreme muscular weakness, easy fatigability, and ptosis are more indicative of other conditions like myasthenia gravis. Choice D is incorrect as numbness of the extremities, loss of balance, and visual disturbances are not classic symptoms of Parkinson's disease.

4. After pericardiocentesis for cardiac tamponade, for which signs should the nurse assess the client to determine if tamponade is recurring?

• A. Decreasing pulse
• B. Rising blood pressure
• C. Distant muffled heart sounds
• D. Falling central venous pressure (CVP)

Correct answer: C

Rationale: After pericardiocentesis for cardiac tamponade, the nurse should assess for distant muffled heart sounds that were noted before the procedure. If these sounds return, it could indicate recurring pericardial effusion and potential tamponade. Therefore, the correct answer is the return of distant muffled heart sounds (Option C). Decreasing pulse (Option A) and falling central venous pressure (Option D) are not specific signs of recurring tamponade. Rising blood pressure (Option B) is also not a typical sign of tamponade recurrence; in fact, hypotension is more commonly associated with tamponade.

5. A nurse performing nasopharyngeal suctioning suddenly notes the presence of bloody secretions. What should the nurse do first?

• A. Continue suctioning to remove the blood
• B. Check the degree of suction being applied
• C. Encourage the client to cough out the bloody secretions
• D. Remove the suction catheter from the client’s nose and begin vigorous suctioning through the mouth

Correct answer: B

Rationale: The correct answer is to check the degree of suction being applied (Choice B). When bloody secretions are encountered during nasopharyngeal suctioning, it is crucial to assess the situation promptly. Checking the degree of suction being applied is the first step as excessive suction pressure may be causing trauma and bleeding. Adjusting the suction pressure may be necessary to prevent further harm. Continuing suctioning to remove the blood (Choice A) or performing vigorous suctioning through the mouth (Choice D) can lead to increased trauma and worsen bleeding. Encouraging the client to cough out the bloody secretions (Choice C) is not appropriate since the client undergoing suctioning is typically unable to expectorate secretions. Therefore, the priority is to check and adjust the suction settings to ensure safe and effective suctioning.

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