Nursing Elites

1. Your patient has shown the following signs and symptoms: Feeling very thirsty, large amount of water intake, dryness of the mouth, and urinary frequency. What physical disorder does this patient most likely have?

• A. Diabetes
• B. Angina
• C. Hypertension
• D. Hypotension

Correct answer: A

Rationale: The patient is exhibiting classic signs of diabetes, such as polydipsia (feeling very thirsty), polyuria (large amount of water intake and urinary frequency), and xerostomia (dryness of the mouth). These symptoms are indicative of high blood glucose levels, which are characteristic of diabetes. Other common signs of diabetes include poor vision, unexplained weight loss, peripheral neuropathy (tingling in the feet and hands), and fatigue. Angina is chest pain due to reduced blood flow to the heart, not associated with the symptoms described in the patient. Hypertension is high blood pressure, which typically does not present with these specific symptoms related to diabetes. Hypotension is low blood pressure and is not consistent with the signs and symptoms presented by the patient, pointing more towards diabetes as the likely diagnosis.

2. What should the nurse in the emergency department do first for a new patient who is vomiting blood?

• A. Insert a large-gauge IV catheter.
• B. Draw blood for coagulation studies.
• C. Check blood pressure (BP), heart rate, and respirations.
• D. Place the patient in the supine position.

Correct answer: C

Rationale: The nurse's initial action should focus on assessing the patient's hemodynamic status by checking vital signs like blood pressure, heart rate, and respirations. This assessment will help determine the patient's immediate needs and guide further interventions. Drawing blood for coagulation studies and inserting an IV catheter are important steps, but they can follow the initial assessment of vital signs. Placing the patient in the supine position can be risky without first assessing the patient's vital signs, as aspiration is a concern. Therefore, assessing vital signs is the priority to ensure appropriate and timely care for the patient.

3. Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis?

• A. Weak, nonproductive cough effort
• B. Large amounts of greenish sputum
• C. Respiratory rate of 28 breaths/minute
• D. Resting pulse oximetry (SpO2) of 85%

Correct answer: A

Rationale: The correct answer is 'Weak, nonproductive cough effort.' A weak, nonproductive cough indicates that the patient is unable to clear the airway effectively, supporting the nursing diagnosis of ineffective airway clearance. In pneumonia, secretions can obstruct the airway, leading to ineffective clearance. Choices B, C, and D do not directly reflect ineffective airway clearance. Large amounts of greenish sputum (Choice B) may suggest infection or inflammation but do not specifically indicate ineffective airway clearance. The respiratory rate of 28 breaths/minute (Choice C) and a resting pulse oximetry (SpO2) of 85% (Choice D) are more indicative of impaired gas exchange or respiratory distress rather than ineffective airway clearance.

4. A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient?

• A. Ask the patient to lie down to complete a full physical assessment.
• B. Briefly ask specific questions about this episode of respiratory distress.
• C. Complete the admission database to check for allergies before treatment.
• D. Delay the physical assessment to first complete pulmonary function tests.

Correct answer: B

Rationale: When a patient presents with acute shortness of breath, the initial assessment should focus on gathering specific information relevant to the current episode of respiratory distress. A comprehensive health history or full physical examination can be deferred until the acute distress has been addressed. Asking specific questions helps determine the cause of the distress and guides appropriate treatment. While checking for allergies is important, completing the entire admission database is not a priority during the initial assessment. Likewise, delaying the physical assessment for pulmonary function tests is not recommended as the immediate focus should be on addressing the acute respiratory distress before ordering further diagnostic tests or interventions.

5. Septic, anaphylactic, and neurogenic shock are all categorized as:

• A. Hypovolemic shock
• B. Cardiogenic shock
• C. Distributive shock
• D. Obstructive shock

Correct answer: C

Rationale: Septic, anaphylactic, and neurogenic shock are all types of distributive shock. Distributive shock is characterized by a decrease in systemic vascular resistance, leading to poor tissue perfusion. Septic shock is caused by severe infection, anaphylactic shock is an extreme allergic reaction, and neurogenic shock results from damage to the nervous system. Hypovolemic shock (Choice A) is characterized by a decrease in intravascular volume, cardiogenic shock (Choice B) is due to heart failure, and obstructive shock (Choice D) results from obstruction of blood flow. Therefore, the correct categorization for septic, anaphylactic, and neurogenic shock is distributive shock.

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