Nursing Elites

1. A client is transferred from the emergency department to the locked psychiatric unit after attempting suicide by taking 200 acetaminophen (Tylenol) tablets. The client is now awake and alert but refuses to speak with the nurse. In this situation, the nurse’s first priority is to:

• A. Establish a rapport to foster trust
• B. Place the client in full restraints
• C. Try to communicate with the client in writing
• D. Ensure safety by initiating suicide precautions

Correct answer: D

Rationale: In this scenario, the nurse's highest priority should be to ensure the client's safety by initiating suicide precautions. Given the history of a suicide attempt by taking a large number of acetaminophen tablets, there is a high risk of further self-harm. Placing the client in full restraints without assessing the situation properly may escalate anxiety and hinder therapeutic communication. Trying to communicate with the client in writing could be an option but ensuring immediate safety takes precedence. Establishing rapport is essential for building trust and therapeutic relationship, but safety concerns must be addressed first in this critical situation.

2. The nurse counsels a client diagnosed with iron deficiency anemia. The nurse determines that teaching is effective if the client selects which of the following menus?

• A. Roast beef, brown rice, green beans, carrot and raisin salad, and milk
• B. Cheese pizza, tossed green salad, oatmeal-raisin cookie, and lemonade
• C. Two scrambled eggs, bacon, white toast with strawberry jam, and coffee
• D. Corn flakes with milk, whole wheat toast, and orange juice

Correct answer: A

Rationale: The correct answer is A. Roast beef is high in heme iron, which is best absorbed and helps treat iron deficiency anemia. Choices B, C, and D do not contain significant sources of iron, especially heme iron, making them less effective in treating iron deficiency anemia.

3. The client is complaining of painful swallowing secondary to mouth ulcers. Which statement by the client indicates appropriate management?

• A. “I will brush my teeth with a soft-bristle toothbrush.”
• B. “I will rinse my mouth with Listerine mouthwash.”
• C. “I will swish my antifungal solution and then swallow.”
• D. “I will avoid spicy foods, tobacco, and alcohol.”

Correct answer: D

Rationale: The correct answer is D. Avoiding irritants like spicy foods, tobacco, and alcohol is crucial in managing mouth ulcers as they can further irritate the ulcers and delay healing. Choices A, B, and C could potentially worsen the condition. Brushing with a soft-bristle toothbrush may cause discomfort, rinsing with Listerine mouthwash can be too harsh on the ulcers, and swallowing antifungal solution is not recommended unless specified by a healthcare provider.

4. Which referral would be most appropriate for the client diagnosed with thoracic outlet syndrome?

• A. The physical therapist
• B. The thoracic surgeon
• C. The occupational therapist
• D. The social worker

Correct answer: C

Rationale: The correct answer is C, the occupational therapist. An occupational therapist specializes in helping individuals with activities of daily living, ergonomic assessments, and adaptive techniques. In the case of thoracic outlet syndrome, an occupational therapist can provide exercises and adaptations to improve the client's function and alleviate symptoms. Choosing the physical therapist (choice A) may also be beneficial for rehabilitation exercises, but occupational therapists focus more on functional activities. Referring to a thoracic surgeon (choice B) would be more appropriate for surgical interventions rather than initial management. Referring to a social worker (choice D) may not directly address the physical symptoms and functional limitations associated with thoracic outlet syndrome.

5. The client is admitted to the emergency department complaining of acute epigastric pain and reports vomiting a large amount of bright red blood at home. Which interventions should the nurse implement?

• A. Assess the client’s vital signs
• B. Start an IV with an 18-gauge needle
• C. Begin iced saline lavage
• D. A, B

Correct answer: D

Rationale: In this scenario, the client's presentation of acute epigastric pain and vomiting bright red blood indicates a potential gastrointestinal bleeding emergency. Assessing the client's vital signs is essential to monitor their hemodynamic status. Starting an IV with an 18-gauge needle is crucial to establish access for potential fluid resuscitation or blood transfusion. Beginning iced saline lavage is not appropriate in this situation and could potentially delay necessary interventions. Therefore, the correct interventions for the nurse to implement are to assess the client’s vital signs and start an IV, making option D the most appropriate choice. Options A and B are correct because they are essential initial steps in managing gastrointestinal bleeding. Option C is incorrect as iced saline lavage is not indicated and may not address the urgent needs of the client in this critical situation.

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