Nursing Elites

1. A client comes into the emergency room and asks to see a doctor. He is anxious, visibly upset, and keeps looking behind him to the waiting room. When the nurse asks his chief complaint, he says, 'My roommate is trying to kill me.' Which of the following is the most appropriate initial response of the nurse?

• A. Just wait here and I will notify security.
• B. I'm going to speak with the physician about getting some medication that may help you.
• C. Why is your roommate trying to kill you?
• D. Have you called the police to report this?

Correct answer: C

Rationale: Upon initial assessment of a client who appears anxious and upset, with claims that need further exploration, the nurse's initial response should be to gather more information about the situation. By asking 'Why is your roommate trying to kill you?' the nurse shows empathy while trying to understand the patient's perspective. This open-ended question allows the nurse to assess the situation comprehensively. Options A and D jump to conclusions or suggest actions without understanding the situation. Option B focuses solely on medication without addressing the underlying issue. It is crucial to assess the situation further before taking any action or providing treatment.

2. Before discharging an anxious client, which information about anxiety would the nurse teach the family?

• A. Anxiety is a totally unique feeling and experience.
• B. Apprehension is generalized to the total environment.
• C. Fears result from conscious actions, thoughts, and wishes.
• D. Anxiety is a pattern of emotional and behavioral responses to stress.

Correct answer: D

Rationale: Anxiety is a human response consisting of both physical and emotional changes that everyone experiences when faced with stressful situations. It is a pattern of emotional and behavioral responses to stress. Anxiety is a common experience for many individuals. Apprehension is usually related to a specific aspect of the environment rather than the total environment. Fears are not intentionally or consciously generated.

3. Which nursing diagnosis has the highest priority when planning care for a client with an indwelling urinary catheter?

• A. Self-care deficit
• B. Functional incontinence
• C. Fluid volume deficit
• D. High risk for infection

Correct answer: D

Rationale: The correct answer is 'High risk for infection.' When caring for a client with an indwelling urinary catheter, the highest priority is to prevent infections, as these catheters are a significant source of infection. Options A and B, self-care deficit and functional incontinence, may be concerns but are not directly related to the indwelling catheter. Option C, fluid volume deficit, is not typically associated with the presence of an indwelling urinary catheter.

4. The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order?

• A. At home, I take my pills at 8:00 am.
• B. It costs a lot of money to buy all of these pills.
• C. I get so tired of taking pills every day.
• D. This is a new pill I have never taken before.

Correct answer: D

Rationale: The client stating, 'This is a new pill I have never taken before,' is the correct answer as it indicates a potential discrepancy in the medication order. This statement requires further assessment to ensure the medication is correct, verify if it is a new prescription or a different manufacturer, and determine if the client needs additional instructions. While the timing of medication administration (option A) is important, it may not be as critical as ensuring the accuracy of the medication being administered. Option B, regarding the cost of pills, is relevant for discharge planning but does not directly impact the immediate administration of the medication. Option C, expressing tiredness from taking pills daily, may warrant discussion on adherence or side effects but does not raise immediate concerns about the specific medication being administered.

5. A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is important for the nurse to provide?

• A. Decrease intake of fluids after the evening meal.
• B. Drink a glass of cranberry juice every day.
• C. Drink a glass of warm decaffeinated beverage at bedtime.
• D. Consult the healthcare provider about a sleeping pill.

Correct answer: A

Rationale: Nocturia is characterized by urination during the night, disrupting sleep patterns. Instructing the client to decrease intake of fluids after the evening meal (Option A) can help reduce the production of urine, thereby decreasing the need to void at night. Cranberry juice (Option B) is beneficial for preventing bladder infections but does not address the issue of nocturia. While warm decaffeinated beverages (Option C) may promote sleep, consuming fluids close to bedtime can exacerbate nocturia. Consulting the healthcare provider about a sleeping pill (Option D) is not the first-line intervention and may lead to urinary incontinence if the client is sedated and unable to awaken to void, worsening the nocturia issue.

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