Nursing Elites

1. A 14-year-old male client with a spinal cord injury (SCI) at T-10 is admitted for rehabilitation. During the morning assessment, the nurse determines that the adolescent's face is flushed, his forehead is sweating, his heart rate is 54 beats/min, and his blood pressure is 198/118. What action should the nurse implement first?

• A. Determine if the urinary bladder is distended
• B. Irrigate the indwelling urinary catheter
• C. Review the temperature graph for the last day
• D. Administer an antihypertensive agent

Correct answer: A

Rationale: Autonomic dysreflexia is a potentially life-threatening emergency that can be triggered by a distended bladder in clients with spinal cord injuries at T-6 or above. The priority action is to determine if the urinary bladder is distended as this could be the cause of the symptoms observed in the adolescent. Flushing, sweating, bradycardia, and severe hypertension are classic signs of autonomic dysreflexia. Irrigating the urinary catheter, reviewing temperature graphs, or administering an antihypertensive agent are not the initial actions to take when suspecting autonomic dysreflexia.

2. What intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an IV site in the client's arm?

• A. Assess IV site frequently for signs of extravasation
• B. Monitor capillary refill distal to the infusion site
• C. Apply a topical anesthetic at the infusion site for burning
• D. Explain that temporary burning at the IV site may occur

Correct answer: A

Rationale: The correct intervention the nurse should implement during the administration of a vesicant chemotherapeutic agent via an IV site in the client's arm is to assess the IV site frequently for signs of extravasation. Vesicants are agents that can cause tissue damage if they leak into the surrounding tissues. Monitoring for signs of extravasation such as swelling, pain, or redness is crucial to prevent tissue damage and ensure prompt intervention if extravasation occurs. Choices B, C, and D are incorrect because monitoring capillary refill, applying a topical anesthetic for burning, and explaining temporary burning do not directly address the risk of extravasation associated with vesicant chemotherapeutic agents.

3. The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized elderly client with an indwelling urinary catheter every two hours. What additional action should the nurse instruct the UAP to take each time the client is turned?

• A. Empty the urinary drainage bag
• B. Feed the client a snack
• C. Offer the client oral fluids
• D. Assess the breath sounds

Correct answer: A

Rationale: The correct additional action the nurse should instruct the UAP to take each time the immobilized elderly client with an indwelling urinary catheter is turned is to empty the urinary drainage bag. This action helps to prevent backflow of urine, reduces the risk of infection, and prevents bladder distention, which are crucial for the client's comfort and health. Choices B, C, and D are incorrect as they are not directly related to the care of a client with an indwelling urinary catheter. Feeding a snack, offering oral fluids, or assessing breath sounds are important aspects of care but not the immediate action needed when turning a client with an indwelling urinary catheter to prevent complications.

4. The mother of a teenager is told that her son has recently been found stealing from other students at school. The mother's response is, 'I cannot think about that today.' The nurse determines that this mother is using which defense mechanism?

• A. Suppression
• B. Repression
• C. Sublimation
• D. Undoing

Correct answer: A

Rationale: The correct answer is A, Suppression. Suppression involves a conscious effort to avoid dealing with distressing thoughts or feelings. In this case, the mother is consciously choosing not to think about her son's behavior. Choice B, Repression, involves unconsciously blocking out distressing thoughts or feelings. Choice C, Sublimation, is the channeling of unacceptable impulses into socially acceptable behaviors, which is not demonstrated in this scenario. Choice D, Undoing, is a defense mechanism where a person tries to undo or reverse a negative thought or action by performing a contrary behavior, which is not applicable here.

5. A woman with an anxiety disorder calls her obstetrician’s office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman?

• A. Describe the safety of certain antianxiety medications during breastfeeding
• B. Encourage her to consider stress-relieving alternatives, such as deep breathing exercises
• C. Inform her that some antianxiety medications are safe to take while breastfeeding
• D. Explain that anxiety is a common response for the mother of a 3-week-old

Correct answer: C

Rationale: The correct answer is C. Some antianxiety medications are considered safe for use while breastfeeding, and the nurse should provide this information to alleviate the woman's concerns. Choice A has been corrected to focus on the safety of certain antianxiety medications during breastfeeding, which is more accurate. Choice B suggests stress-relieving alternatives, which may help but do not address the need for antianxiety medication if required. Choice D is incorrect because it minimizes the woman's concerns by dismissing her increased anxiety as a normal response.

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