Nursing Elites

1. A man who is admitted for a suicide attempt after the death of his child says, 'I hear my son telling me to come over to the other side.' Which psychotic symptom is the client experiencing?

• A. Fixed delusion
• B. Magical thinking
• C. Pathological regression
• D. Command hallucination

Correct answer: D

Rationale: The client is experiencing a command hallucination. Command hallucinations involve auditory messages instructing harm to self or others, and giving an identity to the hallucinated voice increases the risk of compliance. A fixed delusion is a false belief held to be true despite evidence to the contrary. Magical thinking involves believing that thoughts can influence events, commonly seen in young children. Pathological regression refers to reverting to a previous developmental stage, not applicable in this scenario.

2. 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.

3. Which of the following is a nursing intervention for a client who is experiencing an acute panic attack?

• A. Encourage the client to sit down in a quiet environment
• B. Allow the client to direct the situation
• C. Try to focus the client on one aspect of care, such as regulating breathing patterns
• D. Speak in a commanding tone of voice to get the client's attention

Correct answer: C

Rationale: When assisting a client with an acute panic attack, the primary goal is to help reduce their anxiety levels. Encouraging the client to focus on one controllable aspect, like regulating breathing patterns, can aid in calming them down. This intervention helps the client to regain control over their breathing, which can alleviate some of the symptoms associated with panic attacks. Options A and B are incorrect because allowing the client to direct the situation or sit down in a quiet environment may not be beneficial during an acute panic attack. Option D is inappropriate as speaking in a commanding tone can further escalate the client's anxiety rather than helping to calm them down.

4. The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the nurse do next?

• A. Apply a warm compress proximal to the site.
• B. Check for kinks in the tubing and raise the IV pole.
• C. Adjust the tape that stabilizes the needle.
• D. Flush with normal saline and recount the drop rate.

Correct answer: B

Rationale: When encountering a slowed peripheral IV rate, the nurse should initially check for common factors affecting infusion rates. Factors such as the height of the IV bag, presence of kinks in the tubing, needle size or position, client blood pressure, fluid viscosity, and infiltration can impact the rate. It is crucial to ensure the tubing is free of any kinks and that the IV pole is at an appropriate height to facilitate proper flow by gravity. Applying warmth proximal to the site might help with venospasm, but this intervention should come after ensuring proper tubing flow. Adjusting the tape that stabilizes the needle or flushing with normal saline may be necessary later in the troubleshooting process, but these actions should follow checking for kinks and adjusting the IV pole height, which are less invasive interventions.

5. While obtaining a lie-sit-stand blood pressure reading on a client, what action is most important for the nurse to implement?

• A. Stay with the client while the client is standing.
• B. Record the findings on the graphic sheet in the chart.
• C. Keep the blood pressure cuff on the same arm.
• D. Record changes in the client's pulse rate.

Correct answer: A

Rationale: The most crucial action for the nurse to implement when obtaining a lie-sit-stand blood pressure reading is to stay with the client while the client is standing. This is essential to monitor the client's immediate response to position changes and ensure their safety. Recording the findings on the graphic sheet is important for documentation but is not as critical as staying with the client. Keeping the blood pressure cuff on the same arm helps maintain consistency in readings but is not as vital as ensuring client safety. Recording changes in the client's pulse rate is important for a comprehensive assessment but does not take precedence over monitoring the client during position changes.

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