Nursing Elites

1. While assessing a client with diabetes mellitus, the nurse observes an absence of hair growth on the client's legs. What additional assessment provides further data to support this finding?

• A. Palpate for the presence of femoral pulses bilaterally.
• B. Assess for the presence of a positive Homan's sign.
• C. Observe the appearance of the skin on the client's legs.
• D. Watch the client's posture and balance during ambulation.

Correct answer: C

Rationale: The absence of hair growth on the legs in a client with diabetes mellitus can be indicative of poor circulation due to compromised blood flow. Assessing the appearance of the skin on the client's legs is crucial as it can reveal additional signs of impaired circulation, such as changes in color, temperature, and the presence of ulcers or wounds. This information aids in the comprehensive evaluation of the client's vascular status and guides appropriate interventions to prevent potential complications.

2. An elderly client with congestive heart failure (CHF) is admitted to the hospital. Which laboratory test result should the nurse expect to find?

• A. Elevated serum sodium level.
• B. Decreased brain natriuretic peptide (BNP) level.
• C. Increased serum creatinine level.
• D. Elevated hemoglobin and hematocrit levels.

Correct answer: C

Rationale: In clients with congestive heart failure (CHF), impaired cardiac function can lead to decreased renal perfusion, resulting in elevated serum creatinine levels. Therefore, an increased serum creatinine level is a common laboratory finding in CHF clients, indicating possible renal impairment.

3. The preceptor is orienting a new graduate nurse to the critical care unit. The preceptor asks the new graduate to state symptoms that most likely indicate the beginning of a shock state in a critically ill client. What findings should the new graduate nurse identify?

• A. Warm skin, hypertension, and constricted pupils.
• B. Bradycardia, hypotension, and respiratory acidosis.
• C. Mottled skin, tachypnea, and hyperactive bowel sounds.
• D. Tachycardia, mental status change, and low urine output.

Correct answer: D

Rationale: Tachycardia, mental status change, and low urine output are early indicators of shock. In a critically ill client, these findings suggest a decrease in tissue perfusion. Prompt recognition and intervention are crucial to prevent the progression of shock and its complications.

4. What instructions should the nurse give to a patient with cervical cancer who is planned to receive external-beam radiation to prevent complications from the effects of the radiation?

• A. Test stools for the presence of blood.
• B. Maintain a low-residue, high-fiber diet.
• C. Clean the perianal area carefully after every bowel movement.
• D. Inspect the mouth and throat daily for signs of thrush.

Correct answer: C

Rationale: When a patient with cervical cancer is receiving external-beam radiation, the radiation to the abdomen can affect organs in its path, such as the bowel, leading to complications like frequent diarrhea. Cleaning the perianal area carefully after each bowel movement is crucial to decrease the risk of skin breakdown and infection. Testing stools for blood is not necessary since inflammation associated with radiation may lead to occult blood in stools. Maintaining a low-residue diet is actually recommended to prevent bowel irritation. Radiation to the abdomen does not cause stomatitis, so inspecting the mouth and throat for thrush is not directly related to the effects of external-beam radiation in this context.

5. A client with schizophrenia is prescribed haloperidol (Haldol). The nurse should monitor the client for which potential side effect?

• A. Tardive dyskinesia.
• B. Orthostatic hypotension.
• C. Photosensitivity.
• D. Hyperglycemia.

Correct answer: A

Rationale: The correct answer is A: Tardive dyskinesia. Haloperidol (Haldol) is an antipsychotic medication that can lead to tardive dyskinesia, a side effect characterized by involuntary, repetitive movements of the face and body. Monitoring for this side effect is crucial to provide timely interventions and prevent further complications.

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