Nursing Elites

1. A client with schizophrenia is experiencing auditory hallucinations. What is the nurse's best response?

• A. Encourage the client to ignore the voices and stay focused on reality.
• B. Acknowledge the client's feelings and ask what the voices are saying.
• C. Redirect the conversation to help distract the client from the hallucinations.
• D. Offer reassurance that the voices cannot harm the client.

Correct answer: B

Rationale: The best response for a client with schizophrenia experiencing auditory hallucinations is to acknowledge the client's feelings and ask what the voices are saying. This approach helps build rapport with the client, demonstrates empathy, and allows the nurse to assess the content of the hallucinations. Understanding the content is crucial to determine whether the client is at risk of harm. Encouraging the client to ignore the voices (Choice A) may invalidate their experience. Redirecting the conversation (Choice C) may not address the underlying issue of the hallucinations. Offering reassurance (Choice D) without understanding the content may overlook potential risks.

2. A 5-week-old infant with hypertrophic pyloric stenosis has developed projectile vomiting over the last two weeks. Which intervention should the nurse plan to implement?

• A. Instruct the mother to give sugar water only.
• B. Offer the infant oral rehydration every 2 hours.
• C. Provide Pedialyte feedings via nasogastric tube.
• D. Maintain intravenous fluid therapy.

Correct answer: D

Rationale: The correct intervention for a 5-week-old infant with hypertrophic pyloric stenosis presenting with projectile vomiting is to maintain intravenous fluid therapy. This is essential to maintain hydration before surgery. Instructing the mother to give sugar water only (Choice A) is inadequate and does not address the need for proper hydration. Offering oral rehydration every 2 hours (Choice B) may not be effective in cases of severe vomiting and could lead to further fluid loss. Providing Pedialyte feedings via nasogastric tube (Choice C) is an option, but in severe cases, intravenous fluid therapy is more effective in ensuring hydration and electrolyte balance.

3. A client with multiple sclerosis is receiving intravenous methylprednisolone. What is the nurse's priority action?

• A. Monitor blood glucose levels every 6 hours.
• B. Monitor for signs of infection.
• C. Encourage increased oral fluid intake.
• D. Check the client's temperature every 4 hours.

Correct answer: B

Rationale: When a client with multiple sclerosis is receiving intravenous methylprednisolone, the nurse's priority action is to monitor for signs of infection. Corticosteroids like methylprednisolone can suppress the immune system, increasing the risk of infection. Monitoring for signs of infection allows for early detection and prompt intervention. Monitoring blood glucose levels may be important in clients receiving corticosteroids for prolonged periods, but it is not the priority in this case. Encouraging increased oral fluid intake is generally beneficial but not the priority over monitoring for infection. Checking the client's temperature is important but not the priority action compared to monitoring for signs of infection.

4. An S3 heart sound is auscultated in a client in her third trimester of pregnancy. What intervention should the nurse take?

• A. Perform a 12-lead electrocardiogram
• B. Document in the client's record
• C. Notify the healthcare provider immediately
• D. Assess for signs of heart failure

Correct answer: B

Rationale: An S3 heart sound is often a normal finding in pregnant women due to increased blood volume and cardiac output. The nurse should document the finding as part of the routine assessment unless accompanied by other abnormal symptoms. Performing a 12-lead electrocardiogram (Choice A) is unnecessary for a normal S3 heart sound in pregnancy. Notifying the healthcare provider immediately (Choice C) is premature and may lead to unnecessary interventions. Assessing for signs of heart failure (Choice D) is not indicated as an isolated S3 heart sound is typically benign in pregnancy.

5. A client with hypertension is prescribed a beta-blocker. What teaching should the nurse provide about this medication?

• A. Instruct the client to avoid high-potassium foods.
• B. Monitor the client’s heart rate and report any bradycardia.
• C. Advise the client to rise slowly from a sitting or lying position.
• D. Instruct the client to avoid sudden position changes.

Correct answer: C

Rationale: The correct answer is to advise the client to rise slowly from a sitting or lying position. Beta-blockers can cause bradycardia and hypotension, so clients should be advised to rise slowly to prevent dizziness and falls. Monitoring the client's heart rate and blood pressure regularly is essential. Instructing the client to avoid high-potassium foods (Choice A) is not directly related to beta-blockers. While monitoring the client's heart rate (Choice B) is important, advising the client to rise slowly (Choice C) is more directly related to potential side effects of beta-blockers. Instructing the client to avoid sudden position changes (Choice D) is not as specific or essential as advising them to rise slowly to prevent adverse effects.

Similar Questions