Nursing Elites

1. A client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?

• A. Place in a side-lying position with head of bed elevated.
• B. Administer disulfiram (Antabuse) immediately
• C. Give lorazepam (Ativan) PRN for signs of withdrawal.
• D. Provide thiamine and folate supplements as prescribed.

Correct answer: A

Rationale: Maintain the patient's airway is the priority for a client who is intoxicated and obtunded.

2. While interviewing a client, the nurse takes notes to assist with accurate documentation later. Which statement is most accurate regarding note-taking during an interview?

• A. The client’s comfort level is increased when the nurse maintains eye contact while taking notes.
• B. The interview process is enhanced with note-taking, allowing the client to speak at a normal pace.
• C. Note-taking during an interview is not a legal obligation of the examining nurse.
• D. The nurse’s ability to directly observe the client’s nonverbal communication is limited with note-taking.

Correct answer: D

Rationale: During an interview, note-taking can hinder the nurse’s ability to directly observe the client's nonverbal cues such as body language, facial expressions, and tone of voice. These nonverbal cues are crucial for understanding the client's emotions, feelings, and overall communication. Therefore, it is essential for the nurse to strike a balance between note-taking for documentation purposes and actively observing the client's nonverbal communication to ensure a comprehensive assessment. Choices A, B, and C are incorrect because maintaining eye contact, enhancing the interview process with note-taking, and legal obligations of note-taking during an interview do not directly address the issue of limited observation of nonverbal communication while taking notes.

3. Which statement made by a patient prescribed bupropion (Wellbutrin) demonstrates that the medication education the patient received was effective? Select all that apply.

• A. I hope Wellbutrin will help my depression and also help me to finally quit smoking.
• B. I'm happy to hear that I won't need to worry too much about weight gain.
• C. It's okay to take Wellbutrin since I haven't had a seizure in 6 months.
• D. I need to be careful about driving since the medication could make me drowsy.

Correct answer: A

Rationale: Choice A is the correct answer. The patient expressing a desire for Wellbutrin to address both depression and smoking cessation indicates an understanding of the medication's dual benefits. This demonstrates effective medication education as the patient comprehends the drug's purposes. Choice B is incorrect because weight gain is a common side effect of bupropion, so the statement contradicts this fact. Choice C is incorrect as a history of seizures is a contraindication for bupropion, so this statement shows a misunderstanding of the medication's safety profile. Choice D is incorrect because bupropion is not typically associated with sedation, so the concern about drowsiness is not directly related to this medication.

4. A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When a PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the nurse implement first?

• A. Transport the client to the seclusion room.
• B. Quietly approach the client with additional staff members.
• C. Take other clients in the area to the client lounge.
• D. Administer medication to chemically restrain the client.

Correct answer: B

Rationale: In situations where a client is agitated and refusing medication, a non-confrontational approach with additional staff can help de-escalate the situation and address the client's behavior safely. Transporting the client to the seclusion room (Choice A) should not be the initial intervention unless the client poses an immediate risk of harm to themselves or others. Taking other clients to the client lounge (Choice C) does not directly address the agitated client's behavior. Administering medication to chemically restrain the client (Choice D) should only be considered after other de-escalation attempts have been made and if there is a significant safety concern.

5. A healthcare professional is assessing a client for symptoms of post-traumatic stress disorder (PTSD). Which symptom should the healthcare professional expect to find?

• A. Persistent thoughts about the trauma.
• B. Increased energy and enthusiasm.
• C. Decreased need for sleep.
• D. Increased appetite and weight gain.

Correct answer: A

Rationale: The correct answer is A: Persistent thoughts about the trauma. In post-traumatic stress disorder (PTSD), individuals often experience persistent intrusive thoughts about the traumatic event, which can be distressing and disruptive. This symptom is a hallmark feature of PTSD. Choices B, C, and D are incorrect because increased energy, enthusiasm, decreased need for sleep, increased appetite, and weight gain are not typical symptoms of PTSD. Instead, individuals with PTSD may commonly experience symptoms such as flashbacks, nightmares, hypervigilance, avoidance of triggers related to the trauma, and negative changes in mood and cognition.

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