Nursing Elites

1. After attempting suicide by taking 200 acetaminophen (Tylenol) tablets, a client is transferred from the emergency department to the locked psychiatric unit. The client is now awake and alert but refuses to speak with the nurse. In this situation, what is the nurse’s first priority?

• A. Establish a rapport to foster trust
• B. Place the client in full restraints
• C. Try to communicate with the client in writing
• D. Ensure safety by initiating suicide precautions

Correct answer: D

Rationale: The nurse's first priority in this situation is to ensure the client's safety by initiating suicide precautions. This involves removing any potential means of self-harm and closely monitoring the client to prevent further attempts. While establishing rapport and communication are important, safety is paramount at this critical juncture. Placing the client in full restraints should be avoided unless absolutely necessary for immediate safety concerns.

2. Which dietary change is most beneficial for a patient with hypertension?

• A. Increased sodium intake
• B. Decreased potassium intake
• C. Increased fiber intake
• D. Increased cholesterol intake

Correct answer: C

Rationale: The correct answer is C: Increased fiber intake. A diet high in fiber is beneficial for patients with hypertension as it helps lower blood pressure. Increased sodium intake (choice A) is not recommended as it can raise blood pressure. Decreasing potassium intake (choice B) is not advisable as potassium helps regulate blood pressure. Increased cholesterol intake (choice D) is also not recommended as high cholesterol levels can contribute to cardiovascular issues, including hypertension.

3. A client is admitted to the hospital with the diagnosis of a right-sided brain attack (CVA). The client is right-handed. Which task will be most difficult for this client?

• A. Eating meals
• B. Writing letters
• C. Combing the hair
• D. Dressing every morning

Correct answer: B

Rationale: The correct answer is B: Writing letters. Writing requires fine motor skills, which are often impaired in a right-handed person with a right-sided CVA. Eating meals (choice A), combing the hair (choice C), and dressing every morning (choice D) involve gross motor skills and may not be as challenging for a right-handed individual with a right-sided CVA compared to the fine motor skill required for writing.

4. A patient with hypothyroidism should be advised to consume more of which nutrient?

• A. Calcium
• B. Iodine
• C. Vitamin C
• D. Iron

Correct answer: B

Rationale: The correct answer is B: Iodine. Iodine is crucial for the production of thyroid hormones. A deficiency in iodine can lead to hypothyroidism. Calcium (Choice A) is important for bone health but is not directly related to thyroid function. Vitamin C (Choice C) is essential for the immune system and skin health but does not play a significant role in thyroid function. Iron (Choice D) is vital for red blood cell production and oxygen transport but is not specifically relevant to hypothyroidism.

5. The nurse is caring for clients on a medical floor. Which client will the nurse assess first?

• A. The client with an abdominal aortic aneurysm who is constipated
• B. The client on bed rest who ambulated to the bathroom
• C. The client with essential hypertension who has epistaxis and a headache
• D. The client with arterial occlusive disease who has a decreased pedal pulse

Correct answer: C

Rationale: The correct answer is C because epistaxis and headache in a client with hypertension are signs of a hypertensive crisis, requiring immediate intervention. Option A is incorrect as constipation in a client with an abdominal aortic aneurysm, though important, does not indicate an immediate need for assessment. Option B, a client on bed rest who ambulated to the bathroom, does not present with urgent signs or symptoms requiring immediate assessment. Option D, a client with arterial occlusive disease and a decreased pedal pulse, needs attention but is not the priority compared to a hypertensive crisis with epistaxis and headache.

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