Nursing Elites

1. A client tells the nurse he is fearful of planned surgery because of evil thoughts about a family member. What is the best initial response by the nurse?

• A. Call a chaplain
• B. Deny the feelings
• C. Cite recovery statistics
• D. Listen to the client

Correct answer: D

Rationale: The correct answer is to listen to the client. Listening allows the nurse to establish therapeutic communication, understand the client's fears and concerns, provide emotional support, and help alleviate anxiety. Calling a chaplain (Choice A) may be appropriate if the client requests spiritual support but should not be the initial response. Denying the feelings (Choice B) is dismissive and can hinder trust and communication. Citing recovery statistics (Choice C) is irrelevant and does not address the client's immediate emotional needs.

2. To prevent keratitis in an unconscious client, where should the nurse apply moisturizing ointment?

• A. Finger and toenail quicks
• B. Eyes
• C. Perianal area
• D. External ear canals

Correct answer: B

Rationale: The correct answer is B: Eyes. Applying moisturizing ointment to the eyes helps prevent keratitis, a condition that can occur due to inadequate blinking in unconscious clients, leading to corneal dryness and potential damage. Choices A, C, and D are incorrect as moisturizing ointment should not be applied to finger and toenail quicks, perianal area, or external ear canals to prevent keratitis.

3. On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse’s initial response should be to

• A. Give the client orientation materials and review the unit rules and regulations
• B. Introduce oneself and accompany the client to their room
• C. Take the client to the day room and introduce them to the other clients
• D. Ask the nursing assistant to get the client’s vital signs and complete the admission search

Correct answer: B

Rationale: In situations where a client is trembling and fearful upon admission to a psychiatric unit, it is essential to prioritize building trust and reducing anxiety. By introducing oneself and accompanying the client to their room, the nurse can establish a therapeutic relationship, provide a sense of security, and address the client's immediate emotional needs. Choices A, C, and D are not the most appropriate initial responses as they do not directly address the client's emotional state or focus on establishing a supportive relationship.

4. The nurse is assessing a newborn the day after birth. A high-pitched cry, irritability, and lack of interest in feeding are noted. The mother signed her own discharge against medical advice. What intervention is appropriate nursing care?

• A. Reduce the environmental stimuli
• B. Offer formula every 2 hours
• C. Talk to the newborn while feeding
• D. Rock the baby frequently

Correct answer: A

Rationale: The correct intervention is to reduce the environmental stimuli. In this scenario, the newborn is displaying signs of overstimulation and distress, which can be exacerbated by environmental factors. Offering formula every 2 hours (Choice B) may not address the underlying issue of overstimulation. Talking to the newborn while feeding (Choice C) and rocking the baby frequently (Choice D) may further stimulate the newborn, which is not appropriate in this case.

5. A client with tuberculosis is receiving isoniazid (INH). The nurse should monitor the client for which of the following side effects?

• A. Hepatotoxicity
• B. Hyperglycemia
• C. Hypotension
• D. Hypokalemia

Correct answer: A

Rationale: The correct answer is A: Hepatotoxicity. Isoniazid (INH) can lead to hepatotoxicity, necessitating the monitoring of liver function tests. This adverse effect is characterized by liver damage and dysfunction. Choices B, C, and D are incorrect because isoniazid is not typically associated with hyperglycemia, hypotension, or hypokalemia. Therefore, the nurse should focus on assessing for signs and symptoms of hepatotoxicity in a client receiving isoniazid.

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