Nursing Elites

1. The nurse is preparing to administer 10 mL of liquid potassium chloride through a feeding tube, followed by 10 mL of liquid acetaminophen. Which action should the nurse include in this procedure?

• A. Dilute each of the medications with sterile water prior to administration.
• B. Mix the medications in one syringe before opening the feeding tube.
• C. Administer water between the doses of the two liquid medications.
• D. Withdraw any fluid from the tube before instilling each medication.

Correct answer: C

Rationale: Water should be instilled into the feeding tube between administering the two medications to maintain the patency of the feeding tube and ensure that the total dose of medication enters the stomach and does not remain in the tube. These liquid medications do not need to be diluted when administered via a feeding tube. Mixing the medications in one syringe can lead to interactions or alterations in the medications' properties. Withdrawing any fluid from the tube before instilling each medication can cause inaccurate dosing and incomplete administration. Therefore, the correct action is to administer water between the doses of the two liquid medications to ensure proper delivery and avoid any complications.

2. Which clinical findings indicate positive signs and symptoms of schizophrenia?

• A. Withdrawal, poverty of speech, inattentiveness
• B. Flat affect, decreased spontaneity, asocial behavior
• C. Hypomania, labile mood swings, episodes of euphoria
• D. Bizarre behavior, auditory hallucinations, loose associations

Correct answer: D

Rationale: The correct answer is bizarre behavior, auditory hallucinations, and loose associations. These are positive symptoms of schizophrenia, reflecting a distortion or excess of normal function. Withdrawal, poverty of speech, inattentiveness, flat affect, decreased spontaneity, and asocial behavior are negative symptoms linked to schizophrenia, indicating a diminution or absence of normal function. Hypomania, labile mood swings, and episodes of euphoria are more characteristic of bipolar disorder, rather than schizophrenia.

3. Which defense mechanism would the nurse conclude a female client with obsessive-compulsive disorder, who washes her hands more than 20 times a day, is using to ease anxiety?

• A. Undoing
• B. Projection
• C. Introjection
• D. Displacement

Correct answer: A

Rationale: The correct answer is 'Undoing.' Undoing is a defense mechanism where the individual tries to negate a previous act to relieve guilt or anxiety. In this case, the client washing her hands excessively is trying to 'undo' perceived contamination or guilt associated with not washing. Projection (choice B) involves attributing one's own unacceptable thoughts or impulses to others, which is not demonstrated in this scenario. Introjection (choice C) is the process of internalizing beliefs or values of others, which is also not applicable in this context. Displacement (choice D) involves redirecting emotions from one target to another, which does not align with the client's behavior of handwashing as a response to anxiety in this case.

4. When assessing an older adult, which vital sign changes would the nurse recognize as occurring with aging?

• A. Increase in pulse rate
• B. Widened pulse pressure
• C. Increase in body temperature
• D. Decrease in diastolic blood pressure

Correct answer: B

Rationale: When assessing an older adult, the nurse should be aware that with aging, systolic blood pressure tends to increase, resulting in widened pulse pressure. While in many older individuals both systolic and diastolic pressures increase, the pulse rate and body temperature typically do not increase with aging. Therefore, the correct answer is widened pulse pressure. Choices A, C, and D are incorrect because pulse rate does not necessarily increase with age, body temperature generally remains stable, and diastolic blood pressure may increase instead of decreasing in many older adults.

5. The mental health nurse plans to discuss a client's depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best?

• A. Only refer to the client by gender
• B. Identify the client only by age
• C. Avoid using the client's name
• D. Discuss the client another time

Correct answer: D

Rationale: The best nursing action is to discuss the client another time to ensure confidentiality. It is important to maintain the privacy of the client's information, so discussing sensitive topics like depression in a public area where conversations can be overheard is not appropriate. While options A, B, and C may seem like ways to protect the client's identity, they do not guarantee confidentiality since details like gender or age can still lead to identification. Therefore, the nurse should prioritize privacy and confidentiality by finding a more suitable time and location to have a private discussion about the client's concerns.

Similar Questions