Nursing Elites

1. A client begins taking an antidepressant drug during the second day of hospitalization. Which assessment is most important for the nurse to include in this client's plan of care while the client is taking the antidepressant?

• A. Appetite
• B. Mood
• C. Withdrawal
• D. Energy level

Correct answer: B

Rationale: Corrected Rationale: Monitoring the client's mood is essential when starting an antidepressant to assess for any changes or adverse effects related to the medication. Changes in mood can indicate the effectiveness of the antidepressant or potential side effects. Assessing appetite (Choice A) is important but not as crucial as monitoring mood in this context. Withdrawal symptoms (Choice C) are more relevant when discontinuing antidepressants rather than starting them. Energy level (Choice D) can be influenced by various factors and may not directly reflect the client's response to the antidepressant.

2. The nurse is caring for a client who has just received a blood transfusion. The client reports chills and back pain. What is the nurse's priority action?

• A. Slow down the rate of the transfusion
• B. Administer an antipyretic
• C. Stop the transfusion immediately
• D. Notify the healthcare provider

Correct answer: C

Rationale: Chills and back pain are signs of a possible transfusion reaction, which can indicate severe complications like a hemolytic reaction or sepsis. The priority action for the nurse is to stop the transfusion immediately to prevent further harm to the client. Slowing the rate of the transfusion or administering an antipyretic will not address the underlying cause of the reaction and could potentially worsen the client's condition. Notifying the healthcare provider should be done after ensuring the client's immediate safety by stopping the transfusion.

3. During a home visit, a nurse finds that an elderly client is having trouble remembering to take their medications. What is the best intervention?

• A. Set up a pill organizer
• B. Involve family members in care
• C. Arrange for a home health aide
• D. Implement all of the above

Correct answer: D

Rationale: The best intervention when an elderly client is having trouble remembering to take their medications is to implement all of the above options. Setting up a pill organizer helps in organizing and remembering medication schedules. Involving family members in care ensures additional support and reminders. Arranging for a home health aide can provide direct assistance and supervision. Implementing all these strategies together can significantly improve medication adherence, especially in clients with memory issues. Each option plays a crucial role in addressing different aspects of the problem, making 'Implement all of the above' the most comprehensive and effective choice.

4. The nurse is caring for a client who is NPO (nothing by mouth) due to a small bowel obstruction. Which nursing intervention is most important?

• A. Monitor bowel sounds
• B. Provide frequent oral care
• C. Encourage ambulation
• D. Measure abdominal girth

Correct answer: B

Rationale: Providing frequent oral care is crucial when a client is NPO to ensure comfort and prevent drying of the oral mucosa. In this situation, the priority is maintaining oral hygiene to prevent complications such as oral mucosa breakdown. Monitoring bowel sounds may be important in assessing bowel activity, but it is not the priority when the client is NPO due to a small bowel obstruction. Encouraging ambulation can be beneficial for other conditions, but in this case, oral care takes precedence. Measuring abdominal girth is more relevant for assessing abdominal distention, which is not the priority when the client is NPO. Therefore, the most important nursing intervention is to provide frequent oral care.

5. A hospitalized toddler who is recovering from a sickle cell crisis holds a toy and says, 'Mine.' According to Erikson's theory of psychosocial development, this child's behavior is a demonstration of which developmental stage?

• A. Autonomy vs. Shame and Doubt
• B. Industry vs. Inferiority
• C. Initiative vs. Guilt
• D. Trust vs. Mistrust

Correct answer: A

Rationale: The toddler's behavior of asserting possession ('Mine') reflects a desire for independence, aligning with Erikson's stage of Autonomy vs. Shame and Doubt. This stage, typical for toddlers aged 1-3 years, focuses on developing a sense of control and independence. Choices B, C, and D are incorrect: Industry vs. Inferiority relates to middle childhood, Initiative vs. Guilt pertains to preschoolers, and Trust vs. Mistrust is associated with infancy.

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