Nursing Elites

1. What question must the nurse ask when formulating a nursing diagnosis?

• A. What diagnosis did the physician make for this client?
• B. What is the issue that I can solve for this client?
• C. What physician orders will resolve this issue?
• D. What underlying disease does this client have?

Correct answer: B

Rationale: When formulating a nursing diagnosis, the nurse should focus on identifying the client's specific health problems that can be addressed through nursing interventions. The correct answer emphasizes the nurse's role in identifying and addressing client-specific issues through nursing care. Choice A is incorrect because nursing diagnoses are distinct from medical diagnoses made by physicians. Choice C is incorrect as it focuses on physician orders rather than the nurse's role in diagnosing and addressing client problems. Choice D is incorrect because it pertains to identifying underlying diseases, which is not the primary focus of nursing diagnoses.

2. A client with schizophrenia is taking loxapine. Which of the following findings should the nurse identify as the most important to report?

• A. Spasms of the tongue and face
• B. Orthostatic hypotension
• C. Dry mouth
• D. Increased appetite

Correct answer: A

Rationale: Spasms of the muscles of the tongue, face, neck, and back are indicative of acute dystonia, an extrapyramidal manifestation associated with loxapine use. Acute dystonia is a serious condition that can lead to airway obstruction and respiratory compromise. Therefore, the nurse should prioritize reporting this finding to prevent potential harm to the client. Orthostatic hypotension, dry mouth, and increased appetite are common side effects of antipsychotic medications but are not as immediately life-threatening as acute dystonia. Monitoring and managing these side effects are essential for the client's overall well-being, but they do not pose the same level of urgency as addressing acute dystonia.

3. A nurse is assigned to care for a deaf client. During her lunch hour, she visits the hospital library and reads more about deaf culture in order to better provide appropriate care for her client. This action is an example of:

• A. Cultural knowledge
• B. Cultural noise
• C. Cultural diversity
• D. Cultural divide

Correct answer: A

Rationale: Cultural knowledge involves seeking information and educating oneself about different cultural groups. In this scenario, the nurse is demonstrating cultural knowledge by learning more about deaf culture to improve the care provided to the deaf client. This proactive approach helps in understanding the client's background, beliefs, and communication preferences, leading to better outcomes. 'Cultural noise' and 'Cultural divide' are incorrect as they do not reflect the nurse's positive action of seeking knowledge to enhance care. 'Cultural diversity' is also incorrect as it does not accurately describe the nurse's specific action of acquiring knowledge about a particular culture.

4. Thrombolytic therapy is frequently used in the treatment of suspected stroke. Which of the following is a significant complication associated with thrombolytic therapy?

• A. Air embolism.
• B. Cerebral hemorrhage.
• C. Expansion of the clot.
• D. Resolution of the clot.

Correct answer: B

Rationale: Cerebral hemorrhage is a significant complication associated with thrombolytic therapy in stroke treatment. Thrombolytic therapy aims to dissolve clots, but it increases the risk of bleeding, including cerebral hemorrhage. This risk is especially high when the therapy is administered quickly after a stroke, sometimes before confirming the type of stroke. Air embolism (Choice A) is not a common complication of thrombolytic therapy. Expansion of the clot (Choice C) and resolution of the clot (Choice D) are not expected outcomes of thrombolytic therapy; the therapy is specifically used to dissolve clots, not to expand or resolve them.

5. A client returns from surgery after having a colon resection. The nurse is performing an assessment and notes the wound edges have separated. This condition is called:

• A. Evisceration
• B. Hematoma
• C. Dehiscence
• D. Granulation

Correct answer: C

Rationale: Wound dehiscence occurs when the edges of a wound pull apart. The condition may occur following a surgical procedure if the sutures were deficient. Wound dehiscence may also occur following a wound infection or in cases where a client significantly stretches or overuses the associated tissues. Evisceration refers to the protrusion of internal organs through an open wound. Hematoma is a localized collection of blood outside the blood vessels. Granulation is the formation of new connective tissue and tiny blood vessels on the surface of a wound during the healing process.

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