Nursing Elites

1. A client with schizophrenia is experiencing paranoia. What is the nurse's priority intervention?

• A. Reassure the client that their fears are unfounded.
• B. Place the client in a private room to reduce stimuli.
• C. Provide the client with a distraction to redirect their attention.
• D. Encourage the client to express their concerns and validate their feelings.

Correct answer: D

Rationale: Encouraging clients with paranoia to express their concerns and validating their feelings is crucial as it helps establish trust and reduce anxiety. This approach also aids in building a therapeutic relationship. Reassuring the client that their fears are unfounded (Choice A) may invalidate their feelings and worsen trust. Placing the client in a private room to reduce stimuli (Choice B) may be helpful in some situations but does not address the underlying issue of paranoia. Providing a distraction (Choice C) may temporarily shift the client's focus but does not address the root cause of the paranoia. Therefore, the priority intervention is to encourage the client to express their concerns and validate their feelings.

2. A client with a deep vein thrombosis (DVT) is prescribed enoxaparin. What teaching should the nurse provide?

• A. Rotate injection sites to prevent bruising.
• B. Administer the injection in the abdomen only.
• C. Report any unusual bleeding or bruising.
• D. Avoid contact sports to prevent injury.

Correct answer: C

Rationale: The correct teaching for a client prescribed enoxaparin for deep vein thrombosis (DVT) is to report any unusual bleeding or bruising. Enoxaparin is an anticoagulant, and these symptoms could indicate excessive anticoagulation. Choice A is incorrect because with enoxaparin, injections are usually given in the abdomen, not rotated to different sites. Choice D is not directly related to the medication but is a general precaution for individuals at risk of injury.

3. What symptoms suggest the dosage of levothyroxine sodium is too high in a 26-year-old client with simple goiter?

• A. Bradycardia and constipation.
• B. Palpitations and shortness of breath.
• C. Lethargy and lack of appetite.
• D. Muscle cramps and dry skin.

Correct answer: B

Rationale: The correct answer is B: Palpitations and shortness of breath. These symptoms suggest excessive thyroid hormone levels, indicating that the levothyroxine dose is too high. Bradycardia and constipation (choice A) are more indicative of hypothyroidism, which occurs when thyroid hormone levels are low. Lethargy and lack of appetite (choice C) are also common symptoms of hypothyroidism. Muscle cramps and dry skin (choice D) can be associated with various conditions but are not specific to a high dosage of levothyroxine.

4. A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. What action should the nurse take when finding the radiation implant in the bed?

• A. Call radiation therapy for assistance
• B. Place the implant in a lead container using long-handled forceps
• C. Leave the implant in the bed and notify the provider
• D. Dispose of the implant in the nearest sharps container

Correct answer: B

Rationale: The correct action for the nurse to take when finding the radiation implant in the bed is to use long-handled forceps to place the implant in a lead container. This procedure is crucial in reducing radiation exposure to both the patient and healthcare providers. Calling radiation therapy for assistance (Choice A) may delay the immediate need for safe handling of the implant. Leaving the implant in the bed and notifying the provider (Choice C) is unsafe and can lead to increased radiation exposure. Disposing of the implant in a sharps container (Choice D) is incorrect as the implant should be placed in a lead container, not a sharps container, to contain the radiation.

5. When a pediatric client is taking the beta-adrenergic blocking agent propranolol, what signs of overdose should the nurse instruct the parents to report?

• A. Seizures
• B. Increased respiratory rate
• C. Bradycardia
• D. Irritability

Correct answer: C

Rationale: When a pediatric client is taking propranolol, the nurse should instruct the parents to report signs of overdose, including bradycardia. Propranolol is a beta-blocker that can lead to dangerously slow heart rate as a sign of overdose. While increased respiratory rate, seizures, and irritability may occur in some cases, bradycardia is the most critical symptom indicating an overdose of this medication.

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