Nursing Elites

1. Which of the following is the most appropriate example of anticipatory guidance for a 16-year-old who has been hospitalized for an ankle fracture?

• A. Changes associated with puberty
• B. Driving and staying safe
• C. The health hazards of smoking
• D. Social media influences

Correct answer: B

Rationale: Anticipatory guidance is an educational process that provides information important to a client's situation. When considering a 16-year-old who has been hospitalized for an ankle fracture, the most suitable anticipatory guidance would be regarding driving and staying safe. This guidance is crucial as it is age-appropriate and relevant to preventing future injuries. Choices A, C, and D are less pertinent in this scenario. Changes associated with puberty, health hazards of smoking, and social media influences may not directly address the immediate safety concerns of a 16-year-old with an ankle fracture.

2. A nurse is caring for a dying client whose family wants to be with him in the operating suite. The surgeon, however, does not allow families to be present during surgery. The nurse recognizes this as an ethical dilemma. What is the initial step of the nurse when managing this situation?

• A. Contact the physician to amend the order for the client
• B. Document an account of the situation to ensure adequate coverage of details
• C. Consult with the medical ethics committee to determine a safe and workable solution
• D. Speak with the chief nursing officer to change the policy governing this situation

Correct answer: A

Rationale: In this type of situation, the first action of the nurse should be to address the immediate needs of the client by requesting the physician to make a change based on the circumstances. The primary concern is to ensure the client's well-being and honor the family's wishes, even if it means deviating from standard protocols. While documentation (Choice B) and consulting with higher authorities like the medical ethics committee (Choice C) may be necessary at a later stage, the initial step is to take action to meet the client's needs promptly. Speaking with the chief nursing officer to change the policy (Choice D) is not the most immediate or practical step in this situation, as the focus should be on the client's current care needs.

3. A client on lithium has diarrhea and vomiting. What should the nurse do first?

• A. Recognize this as a drug interaction
• B. Give the client Cogentin
• C. Reassure the client that these are common side effects of lithium therapy
• D. Hold the next dose and obtain an order for a stat serum lithium level

Correct answer: D

Rationale: Diarrhea and vomiting are manifestations of lithium toxicity. The priority action for the nurse is to hold the next dose of lithium and obtain an order for a stat serum lithium level to confirm toxicity. This ensures patient safety and prevents further harm. Recognizing it as a drug interaction is not the first step in this scenario. Cogentin is used to manage extrapyramidal symptoms (EPS) associated with antipsychotics, not lithium toxicity. Reassuring the client about these symptoms as common side effects of lithium therapy is inappropriate as they indicate a more serious issue than typical side effects like hand tremors, nausea, polyuria, and polydipsia.

4. What is the highest priority for post ECT care?

• A. Observe for confusion
• B. Monitor respiratory status
• C. Reorient to time, place, and person
• D. Document the client's response to the treatment

Correct answer: B

Rationale: The highest priority for post ECT care is to monitor respiratory status. This is crucial because a life-threatening side effect of ECT is respiratory arrest. While observing for confusion and reorienting the client are important aspects of post ECT care, they are not as critical as ensuring the client's respiratory status is stable. Documenting the client's response to treatment is also important for maintaining accurate medical records, but it is not the highest priority immediately post ECT.

5. A 27-year-old 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 staff to be with the client at all times to help maintain control

Correct answer: A

Rationale: For a manic client who is hyperactive and may engage in injurious activities, setting realistic limits to the client's behavior is crucial to ensure safety. A quiet environment with firm and consistent limits helps in managing the client's behavior effectively. While repeating verbal instructions can be helpful due to the client's distractibility, it is not the priority compared to setting limits for safety concerns. Allowing the client to express feelings is important, but it should be done through non-destructive methods. Assigning staff to be with the client at all times is not realistic or feasible in the clinical setting and does not address the core issue of managing the client's behavior and ensuring safety.

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