Nursing Elites

1. A client with pancreatitis has been transferred to the intensive care unit. Which order would the nurse anticipate?

• A. Blood pressure monitoring every 15 minutes
• B. Insertion of a Levine tube
• C. Continuous cardiac monitoring
• D. Administration of pain medication every 4 hours

Correct answer: B

Rationale: In a client with pancreatitis who frequently experiences nausea and vomiting, insertion of a Levine tube is often anticipated to decompress the stomach and rest the bowel, helping to alleviate symptoms. This intervention is crucial in managing the gastrointestinal symptoms associated with pancreatitis. Blood pressure monitoring every 15 minutes may be necessary in some cases, but it is not a routine order for pancreatitis, making option A less likely. Continuous cardiac monitoring could be required based on the individual's condition, but it is not typically the first priority in pancreatitis management, so option C is not the most anticipated order. While pain medication administration is essential for managing discomfort, the priority in this scenario, especially considering the symptoms of nausea and vomiting, would be decompression with a Levine tube to address gastrointestinal issues, making option D less likely.

2. Which of the following statements is correct regarding rape?

• A. Most rapes go unreported.
• B. Legally, a woman can be raped by her spouse.
• C. Prosecuting and convicting for rape can be challenging.
• D. Rape can occur in different locations.

Correct answer: B

Rationale: The correct statement is that legally, a woman can be raped by her spouse. Rape is defined as sexual intercourse against someone's will, and it can occur between any two persons regardless of their relationship, including spouses. Choice A is incorrect as most rapes are not reported due to various reasons like fear, shame, or distrust in the legal system. Choice C is incorrect as prosecuting and convicting for rape can be challenging due to factors like lack of evidence, societal biases, and victim blaming. Choice D is incorrect as the most common location of rape is not necessarily the victim's own home; it can happen in various settings such as public places, workplaces, or social gatherings.

3. A client with a diagnosis of Schizophrenia has been released from an acute care setting. The client had a prolonged recovery from relapse. One of the parents says to the discharge nurse, 'I do not understand what is going on. The hospital said she was better, but all she does is sit around all day and smoke. We cannot get her to go to the vocational training you arranged.' The nurse recognizes that more teaching is needed about

• A. the pathophysiology and behavioral manifestations of schizophrenia.
• B. support groups that can help the parents cope with their frustration.
• C. the prolonged recovery time and side effects of medications to prevent relapse.
• D. motivational techniques that are effective in engaging clients with schizophrenia.

Correct answer: C

Rationale: The nurse conducting discharge teaching must emphasize the extended recovery process and the potential side effects of medications used to prevent relapse in individuals with schizophrenia. In this scenario, it is crucial for the parents to understand that the client's behavior may be influenced by the medication's sedative qualities and the time required for full recovery. While support groups can assist caregivers in coping with their emotions and providing better care, the priority here is educating on the recovery process and medication effects. Motivational techniques are beneficial but may not be the immediate focus in this situation.

4. Which of the following describes the stages of domestic violence in an intimate relationship?

• A. happiness, crisis, angry outburst, intervention
• B. honeymoon period, escalation of stress, outburst, reconciliation
• C. acting out and making up
• D. peace and calm, angry outburst, peace and calm, denial

Correct answer: B

Rationale: The correct answer is B: 'honeymoon period, escalation of stress, outburst, reconciliation.' A pattern of behavior known as the cycle of abuse involves these stages. It starts with a honeymoon phase, followed by a buildup of stress, an outburst which may involve violence, and then reconciliation. This cycle is commonly observed in domestic violence situations. Choices A, C, and D do not accurately represent the stages of domestic violence in intimate relationships. Choice A mixes positive and negative elements, while choice C simplifies the complex dynamics of domestic violence. Choice D repeats 'peace and calm' inappropriately and includes 'denial,' which is not typically a stage in the cycle of abuse.

5. A client arrives in the emergency room with a possible fractured femur. The nurse should anticipate an order for:

• A. Trendelenburg position
• B. Ice to the entire extremity
• C. Buck's traction
• D. An abduction pillow

Correct answer: C

Rationale: The correct answer is Buck's traction. This intervention is used to realign the fractured femur, reduce spasms, and alleviate pain. Placing the client in the Trendelenburg position is inappropriate for a femur fracture, making answer A incorrect. While ice may be used post-repair, applying it to the entire extremity is unnecessary, so answer B is wrong. An abduction pillow is typically employed following a total hip replacement, not for a fractured femur, rendering answer D incorrect.

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