Nursing Elites

1. A nurse has been caring for a female client who has bruises on her arms that she explains are a result of physical abuse by her husband. The client states, “I don’t know how much longer I can take this, but I’m afraid he’ll really hurt me if I leave.” Which of the following is an appropriate nursing intervention?

• A. Offer to speak to the client’s husband regarding his abusive behavior
• B. Help the client to recognize signs of escalation in abusive behavior
• C. Assist the client in identifying personal behaviors that trigger abuse
• D. Assist the client in reporting the abusive behavior to authorities

Correct answer: D

Rationale: Assisting the client in reporting the abuse is a critical step in ensuring her safety and initiating legal action to protect her from further harm. Option A is inappropriate as it may escalate the situation and put the client at further risk. Option B focuses on the client recognizing signs of abuse, which is not as urgent as reporting it to authorities. Option C places the responsibility on the client for triggering the abuse, which is victim-blaming and not helpful in this context.

2. A nurse is caring for a postmenopausal client prescribed the aromatase inhibitor anastrozole for the treatment of breast cancer. Which of the following should the nurse inform the client she may experience?

• A. Weight gain
• B. Muscle and joint pain
• C. Night sweats
• D. Increased appetite

Correct answer: B

Rationale: The correct answer is B: Muscle and joint pain. Muscle and joint pain are common side effects of aromatase inhibitors like anastrozole. These side effects can be managed with analgesics as prescribed by the healthcare provider. Weight gain (choice A) is not typically associated with anastrozole. Night sweats (choice C) are also not commonly reported with this medication. Increased appetite (choice D) is not a common side effect of anastrozole.

3. A client is receiving enoxaparin for the prevention of DVT. Which of the following is an appropriate action by the nurse?

• A. Expel any air bubbles from the prefilled syringe
• B. Massage the injection site to aid in absorption of the medication
• C. Inject the medication into the lateral abdominal wall
• D. Administer an NSAID for injection site discomfort

Correct answer: C

Rationale: The correct answer is to inject enoxaparin into the lateral abdominal wall for subcutaneous absorption. This site is commonly used for administering this type of medication. Expelling air bubbles from the syringe is not necessary and may result in a reduced dose being administered. Massaging the injection site is not recommended as it can lead to bruising or irritation. Administering an NSAID for injection site discomfort is not indicated as discomfort at the injection site is usually minimal and self-limiting.

4. A client is prescribed spironolactone. Which of the following dietary instructions should the nurse include?

• A. Increase potassium-rich foods
• B. Limit sodium intake
• C. Avoid potassium supplements
• D. Increase protein intake

Correct answer: C

Rationale: The correct answer is to advise the client to avoid potassium supplements. Spironolactone is a potassium-sparing diuretic, meaning it helps the body retain potassium. Adding potassium supplements on top of this medication can lead to hyperkalemia, an elevated level of potassium in the blood, which can be dangerous. Choices A, B, and D are incorrect because increasing potassium-rich foods, limiting sodium intake, and increasing protein intake are not specifically related to the dietary considerations when taking spironolactone.

5. A nurse is reviewing the medication class, benzodiazepines. The nurse would use caution when administering benzodiazepines to which of the clients below?

• A. A client with glaucoma
• B. A client with renal failure
• C. A client with hypertension
• D. A client with insomnia

Correct answer: A

Rationale: Benzodiazepines can increase intraocular pressure, which is why they must be used cautiously in patients with glaucoma. In clients with this condition, benzodiazepines can potentially worsen symptoms and lead to further complications involving the eyes. Therefore, administering benzodiazepines to a client with glaucoma should be done with caution. Choices B, C, and D are not directly contraindicated with benzodiazepines, making them less likely to cause harm compared to administering to a client with glaucoma.

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