Nursing Elites

1. 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.

2. While assessing a one-month-old infant, which of the findings does not warrant further investigation by the nurse?

• A. Abdominal respirations
• B. Inspiratory grunt
• C. Nasal flaring
• D. Cyanosis

Correct answer: A

Rationale: Abdominal respirations in infants are considered normal due to the underdeveloped intercostal muscles. Infants rely more on their abdominal muscles to facilitate breathing since their intercostal muscles are not fully matured. Therefore, abdominal respirations do not typically require further investigation. Inspiratory grunt, nasal flaring, and cyanosis are findings that warrant additional assessment as they can indicate potential respiratory distress or other underlying health issues in infants. Inspiratory grunt may suggest respiratory distress, nasal flaring can be a sign of increased work of breathing, and cyanosis indicates poor oxygenation, all of which require prompt evaluation and intervention to ensure the infant's well-being.

3. Mr. K is admitted to the orthopedic unit one morning in preparation for a total knee replacement to start in two hours. Which of the following is a priority topic to instruct this client on admission?

• A. The approximate length of the surgery
• B. The type of anticoagulants that will be prescribed
• C. The time of the next meal of solid food
• D. The length of time until the client can return to work

Correct answer: A

Rationale: The priority topic to instruct a client admitted for a total knee replacement surgery should be the approximate length of the surgery. Pre-surgical teaching should focus on preparing the client for the upcoming procedure. Providing information about the duration of the surgery can help manage the client's expectations, reduce anxiety, and ensure they are mentally prepared for the operation. While details about post-operative care, anticoagulants, meals, and return to work are important, they are not the immediate priority during the preoperative phase. These aspects can be addressed at a later stage in the client's care journey.

4. After Brandon is stabilized following his second myocardial infarction due to cocaine use, what collaborative process should begin to connect him with additional resources?

• A. Law enforcement for further prevention
• B. Social services for rehab
• C. Narcotics Anonymous
• D. Financial counselor to apply for assistance

Correct answer: B

Rationale: Following stabilization, it is essential to connect Brandon with additional resources to address his addiction. Social services are a crucial collaborative partner in this situation because they have access to community resources that can support Brandon's rehabilitation needs. While law enforcement may be involved in certain situations, their primary role is not to provide rehabilitation services. Narcotics Anonymous is a valuable support group but does not offer the comprehensive services that social services for rehab can provide. A financial counselor may be beneficial for addressing financial concerns, but the priority at this stage is to address Brandon's addiction through appropriate rehabilitation services.

5. Which of the following conditions may cause an increased respiratory rate?

• A. Stooped posture
• B. Narcotic analgesics
• C. Injury to the brain stem
• D. Anemia

Correct answer: D

Rationale: Anemia can lead to an increased respiratory rate. In anemia, there are decreased levels of hemoglobin in red blood cells, which are responsible for carrying oxygen to the body's tissues. To compensate for the reduced oxygen-carrying capacity, the body increases the respiratory rate to bring in more oxygen. Stooped posture (Choice A) is not directly related to an increased respiratory rate. Narcotic analgesics (Choice B) are more likely to cause a decreased respiratory rate due to their central nervous system depressant effects. Injury to the brain stem (Choice C) can affect respiratory function but may not necessarily lead to an increased respiratory rate.

Similar Questions