Nursing Elites

1. A client is admitted with a diagnosis of Multiple Drug Use. The nurse should plan care based on knowledge that

• A. Multiple drug use is common.
• B. People might use more than one drug to enhance the effect or relieve withdrawal symptoms.
• C. Combining alcohol and barbiturates can be dangerous due to their combined depressant effects.
• D. Assessment and intervention are more complex with multiple drug use due to the synergistic effects.

Correct answer: B

Rationale: When caring for a client with Multiple Drug Use, it is important to understand that individuals may use more than one drug simultaneously or sequentially to enhance the effect of a particular drug or to relieve withdrawal symptoms. This practice is common among substance users. For example, heroin users may also consume alcohol, marijuana, or benzodiazepines. Combining drugs can have various effects, such as intensifying intoxication or alleviating withdrawal symptoms. It is crucial to recognize that multiple drug use can complicate assessment and intervention due to the diverse effects of different substances on the client's health. Option A is incorrect as multiple drug use is indeed common, not uncommon. Option C is incorrect because combining alcohol and barbiturates can be dangerous due to their combined depressant effects. Option D is incorrect because multiple drug use complicates assessment and intervention rather than making them easier, as the effects of different drugs on the client need to be carefully considered.

2. The nurse is preparing a client for surgery. Which item is most important to remove before sending the client to surgery?

• A. Hearing aid
• B. Contact lenses
• C. Wedding ring
• D. Artificial eye

Correct answer: B

Rationale: The correct answer is B: Contact lenses. It is crucial to remove contact lenses before surgery to prevent corneal drying, especially with non-extended wear lenses. Leaving the hearing aid or artificial eye in place does not pose harm to the client during surgery. While wedding rings are typically covered with tape, leaving them on is acceptable. Therefore, choices A, C, and D are incorrect in this scenario.

3. An adolescent female reports being raped at a party where alcohol was served. The client admits to drinking alcohol before being raped by an acquaintance. The nurse should:

• A. inform the client that because she is underage, she is not at fault for attending a party where alcohol was served.
• B. ask the client if anyone witnessed the event because the client was intoxicated and might not remember it accurately.
• C. inform the client that it was not her fault, and support the client through the physical examination.
• D. question whether the woman had consensual sex and now just feels guilty.

Correct answer: C

Rationale: In cases of rape, it is crucial to provide support and reassurance to the victim. The nurse should inform the client that it was not her fault and offer support through the physical examination. Blaming the victim, as in choice A, is inappropriate and can be damaging to the client's well-being. Choice B is not the priority at this moment; the immediate focus should be on supporting the client. Choice D is victim-blaming and implies doubt about the client's report, which is harmful and not supportive. It is essential to create a safe and supportive environment for the client to facilitate healing and recovery.

4. Several clients are admitted to the emergency room following a three-car vehicle accident. Which clients can be assigned to share a room in the emergency department during the disaster?

• A. The schizophrenic client experiencing visual and auditory hallucinations and the client with ulcerative colitis
• B. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm
• C. A child with fixed and dilated pupils and his parents, and the client with a frontal head injury
• D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain

Correct answer: B

Rationale: The correct answer is to assign the client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm to share a room. The pregnant client needs close monitoring due to the abdominal pain, and the client with facial lacerations and a broken arm requires immediate attention for wound care and possible fracture management. Choice A should not be assigned together as the schizophrenic client experiencing visual and auditory hallucinations needs a separate room for privacy and safety, and the client with ulcerative colitis may require isolation due to the risk of infection. Choice C is incorrect because the child with fixed and dilated pupils is likely in a critical condition and should be in a private room with parents, while the client with a frontal head injury needs a separate room for focused care. Choice D is also incorrect as the client with a large puncture wound to the abdomen needs immediate attention in a separate room, and the client with chest pain requires evaluation and monitoring in a separate setting as well.

5. The nurse is working with families who have been displaced by a fire in an apartment complex. What is the priority intervention during the initial assessment?

• A. Provide a liaison to meet housing needs.
• B. Attentively listen when clients describe their feelings.
• C. Offer nurturing support for clients who are confused by the events.
• D. Provide structure for clients exhibiting moderate to severe anxiety.

Correct answer: A

Rationale: The correct answer is to provide a liaison to meet housing needs. In the initial assessment after a disaster like a fire, ensuring basic needs such as housing, clothing, and food are met is the priority. Once the physical needs are addressed, the nurse can then focus on assisting clients in managing the psychological effects of loss. Choices B, C, and D are not the priority during the initial assessment as addressing housing needs should come first to provide a sense of stability and security for the affected families.

Similar Questions