Nursing Elites

1. A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first?

• A. Inform the client that the blood pressure is high and compare the reading with the client's previously documented blood pressure readings for accuracy.
• B. Contact the health care provider to report the reading and obtain a prescription for an antihypertensive medication.
• C. Replace the cuff with a larger one to ensure a proper fit for the client and increase arm comfort during blood pressure measurement.
• D. Compare the current reading with the client's previously documented blood pressure readings.

Correct answer: D

Rationale: The correct action for the nurse to take first when a client's blood pressure reading is 156/94 mm Hg is to compare the current reading with the client's previously documented readings. This comparison helps determine whether the current reading is abnormal for the client. Option A, which involves informing the client that the blood pressure is high and comparing it with the previous readings, is appropriate as it educates the client and aids in accurate assessment. Option B, contacting the health care provider for medication, is premature without further assessment. Option C, replacing the cuff with a larger one, is incorrect as it may affect the accuracy of the blood pressure measurement and is not a standard practice for managing high blood pressure readings.

2. Which response would the nurse make to a client who says, 'The voices say I'll be safe only if I stay in this room, wear these clothes, and avoid stepping on the cracks between the floor tiles'?

• A. Ask whether the voices are male or female and how many there are.
• B. Reassure the client by stating, 'I understand that these voices are real to you, but I want you to know that I don't hear them.'
• C. Offer false reassurance by saying, 'Don't worry"?I've locked the door to your room and won't let anyone in.'
• D. Encourage the client to leave the room and keep busy to distract from the voices.

Correct answer: B

Rationale: The response, 'I understand that these voices are real to you, but I want you to know that I don't hear them,' demonstrates empathy and validation of the client's experience while also gently bringing in the nurse's reality. This response acknowledges the client's feelings without reinforcing the hallucinations. Asking about the characteristics of the voices (Choice A) can inadvertently validate the hallucinations. Offering false reassurance (Choice B) may not be helpful as it does not address the client's distress. Encouraging the client to leave the room and keep busy (Choice D) is nontherapeutic as it disregards the client's experience and may increase anxiety.

3. The client prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which intervention(s) is(are) correct?

• A. Place the client in a high Fowler position.
• B. Assist the client in assuming a left side-lying position.
• C. Measure the tube from the tip of the nose to the xiphoid process.
• D. Assist the client in flexing the neck forward to facilitate tube insertion.

Correct answer: A

Rationale: The correct intervention during nasogastric tube insertion in an awake and alert client is to place them in a high Fowler position (A). Left side-lying position (B) is more suitable for unconscious or obtunded clients. When measuring the tube length, it should be from the tip of the nose to behind the ear, and then from behind the ear to the xiphoid process (C). Assisting the client in flexing the neck forward (D) is appropriate to facilitate tube insertion rather than extending the neck back, which may lead to complications. Proper positioning and measurements are crucial to prevent complications and ensure successful nasogastric tube placement.

4. A client with invasive carcinoma of the bladder is scheduled for a cystectomy and an ileal conduit. The client expresses worries about the possibility of offensive odors associated with the urinary diversion. How would the nurse respond?

• A. ''Tell me more about your concerns.''
• B. ''Products are available to address this issue.''
• C. ''This is a valid concern, and we can discuss ways to manage it.''
• D. ''Many individuals who undergo this procedure have similar worries.''

Correct answer: A

Rationale: The response ''Tell me more about your concerns'' is open-ended, encouraging the client to express their worries freely. This approach fosters communication and shows empathy. Option B acknowledges the concern and offers a solution, demonstrating support and understanding. Option C validates the client's worry and suggests collaboration in finding solutions. Option D normalizes the concern but may not address the client's specific worries, making it less therapeutic than the other options. Overall, actively listening to the client's concerns and offering support are essential in providing holistic care.

5. What is a priority goal of involuntary hospitalization of the severely mentally ill client?

• A. Re-orientation to reality
• B. Elimination of symptoms
• C. Protection from harm to self or others
• D. Return to independent functioning

Correct answer: C

Rationale: The priority goal of involuntary hospitalization of severely mentally ill clients is to ensure protection from harm to self or others. Involuntary hospitalization is often necessary for individuals who are deemed dangerous to themselves or others or who are considered gravely disabled. Re-orientation to reality, elimination of symptoms, and return to independent functioning are important aspects of mental health care but are not the primary goals of involuntary hospitalization. The main focus during involuntary hospitalization is to address safety concerns and prevent harm.

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