Nursing Elites

1. A nurse is providing discharge instructions for a client who had back surgery. All of the following indicate that the client is ready for discharge EXCEPT:

• A. The client still has sutures at the incision site
• B. The client is able to take a shower
• C. The client must still use an ice pack at the wound site
• D. The client has a temperature of 100.8�F

Correct answer: D

Rationale: When determining if a client is ready for discharge after back surgery, it is essential to ensure that there are no signs of complications or emerging issues. A postoperative temperature of 100.8�F may indicate a developing infection, and the client should not be discharged until this is further evaluated by the physician. Choices A, B, and C are indicators that the client is progressing well and ready for discharge, as having sutures, being able to shower, and using an ice pack are typically expected postoperative activities without indicating a need for further hospitalization.

2. A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol) 50 mg bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10 mg HS. Which client behavior would warrant the nurse to administer benztropine?

• A. Tactile hallucinations
• B. Tardive dyskinesia
• C. Restlessness and muscle rigidity
• D. Reports of hearing disturbing voices

Correct answer: C

Rationale: Benztropine (Cogentin) is an anticholinergic medication used to treat extrapyramidal symptoms, such as restlessness and muscle rigidity, which are common side effects of antipsychotic medications like haloperidol. Tactile hallucinations and reports of hearing disturbing voices are symptoms of schizophrenia that would typically be addressed by the antipsychotic medication (haloperidol) itself. Tardive dyskinesia, a potential side effect of long-term antipsychotic use, would require discontinuation of the antipsychotic medication rather than administration of benztropine.

3. Mr. W has orders for a physical therapy consult. The nurse contacts the appropriate department but 12 hours later, no one has come to see the client. Which is the most appropriate action of the nurse?

• A. Call the supervisor and file a complaint against the physical therapy department
• B. Contact the physician to notify him that the orders were not carried out
• C. Assess the client's activity level by assisting with ambulation using a gait belt
• D. Contact the physical therapy department again and repeat the order

Correct answer: D

Rationale: In this situation, the most appropriate action for the nurse to take is to contact the physical therapy department again and repeat the order. It is crucial to ensure that the client receives the necessary care as prescribed. Following up with the department reinforces the importance of the order and increases the likelihood of prompt action. Option A is incorrect because escalating the situation to filing a complaint should be a last resort after all other communication attempts have failed. Option B is not the best course of action as the first step should be to ensure proper communication within the healthcare team. Option C is not the priority in this scenario, as the immediate concern is to address the delay in the physical therapy consult.

4. A writer is admitted for the second time accompanied by his wife. He is demanding, arrogant, talks fast, and is hyperactive. Initially, the nurse should plan this for a manic client:

• A. Set realistic limits to the client's behavior
• B. Repeat verbal instructions as often as needed
• C. Allow the client to express feelings to relieve tension
• D. Assign a staff member to be with the client at all times to help maintain control

Correct answer: A

Rationale: For a manic client who is demanding, arrogant, talks fast, and is hyperactive, setting realistic limits to the client's behavior is essential to ensure safety as manic clients may engage in injurious activities. A quiet environment and consistent, firm limits help to maintain control. While repeating verbal instructions may be necessary due to distractibility, it is not the priority compared to setting limits for safety. Allowing the client to express feelings is important, but only non-destructive methods of expression should be permitted. Assigning a staff member to be with the client at all times is not a realistic approach as it may not always be feasible or necessary for managing manic behavior effectively.

5. A patient with peripheral vascular disease is receiving discharge instructions. Which of the following information should be included?

• A. Walk barefoot whenever possible.
• B. Use a heating pad to keep feet warm.
• C. Avoid crossing the legs.
• D. Use antibacterial ointment to treat skin lesions prone to infection.

Correct answer: C

Rationale: Patients with peripheral vascular disease should be advised to avoid crossing their legs as this can impede blood flow. Peripheral vascular disease, also known as arteriosclerosis obliterans, is primarily caused by atherosclerosis. Atherosclerosis results in the gradual progression of arterial occlusion due to the formation of atheromas. Crossed legs can further restrict blood flow, exacerbating the condition. Walking barefoot should be discouraged to prevent potential injuries to the feet. Using a heating pad can lead to burns and should be avoided to prevent thermal injuries. While using antibacterial ointment for skin lesions may be beneficial, it is not the priority instruction for patients with peripheral vascular disease.

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