Nursing Elites

1. A nurse is assessing a client who has just returned from surgery and is experiencing acute pain. Which of the following findings should the nurse expect?

• A. Bradycardia.
• B. Hypotension.
• C. Diaphoresis.
• D. Hyperactive bowel sounds.

Correct answer: C

Rationale: The correct answer is C: Diaphoresis. Diaphoresis, which is excessive sweating, is a common response to acute pain due to increased sympathetic nervous system activity. Options A and B, Bradycardia and Hypotension, are unlikely findings in a client experiencing acute pain as pain usually triggers an increase in heart rate (tachycardia) and blood pressure. Option D, Hyperactive bowel sounds, is not typically associated with acute pain.

2. A charge nurse is teaching new staff members about factors that increase a client's risk of becoming violent. Which of the following risk factors should the nurse include as the best predictor of future violence?

• A. Experiencing delusions.
• B. Male gender.
• C. Previous violent behavior.
• D. A history of being in prison.

Correct answer: C

Rationale: The correct answer is C: Previous violent behavior. This is the best predictor of future violence as individuals who have a history of violent behavior are more likely to engage in violent acts in the future. While experiencing delusions and being male may contribute to an increased risk of violence in certain situations, they are not as strong predictors as a history of violence. Similarly, having a history of being in prison may indicate a higher likelihood of violence, but it is not as directly linked to future violent behavior as previous violent actions.

3. If a nurse administers an incorrect dose of medication, which fact related to the incident report should the nurse document in the client's medical record?

• A. Time the medication was given
• B. The client's response to the medication
• C. The dose that was administered
• D. Reason for the error

Correct answer: A

Rationale: The correct answer is to document the time the medication was given. This is essential for understanding the sequence of events surrounding the medication error. While documenting the client's response to the medication (Choice B) is important for assessing any effects, the immediate concern should be to establish a clear timeline by documenting the time of administration. Recording the dose administered (Choice C) is also important, but in the context of understanding the incident, the time factor takes precedence. The reason for the error (Choice D) should be included in the incident report but may not be the first priority when documenting in the client's medical record.

4. A nurse is caring for a client who has depression and reports taking St. John's wort along with citalopram. The nurse should monitor the client for which of the following conditions as a result of an interaction between these substances?

• A. Serotonin syndrome
• B. Tardive dyskinesia
• C. Pseudo-parkinsonism
• D. Acute dystonia

Correct answer: A

Rationale: The correct answer is A: Serotonin syndrome. When a client takes St. John's wort, a herbal supplement, along with citalopram, a selective serotonin reuptake inhibitor (SSRI), there is a risk of developing serotonin syndrome. Serotonin syndrome is a potentially life-threatening condition characterized by symptoms such as confusion, agitation, fever, sweating, shivering, tremors, muscle rigidity, and in severe cases, seizures and coma. It is crucial for the nurse to monitor the client for these symptoms. Choices B, C, and D are incorrect because tardive dyskinesia is associated with long-term use of antipsychotic medications, pseudo-parkinsonism is a side effect of antipsychotic medications like haloperidol, and acute dystonia is a side effect of antipsychotic medications characterized by sustained muscle contractions.

5. A client with a new prescription for levothyroxine is receiving discharge teaching. Which of the following client statements indicates an understanding of the teaching?

• A. I should take this medication with food to prevent nausea.
• B. I will take this medication every morning before breakfast.
• C. I will stop taking this medication if I experience chest pain.
• D. I will take this medication at bedtime.

Correct answer: B

Rationale: The correct answer is B. Levothyroxine should be taken every morning before breakfast to enhance absorption and maintain consistent thyroid hormone levels. Option A is incorrect because levothyroxine should be taken on an empty stomach. Option C is incorrect because chest pain is not a common side effect of levothyroxine and stopping the medication abruptly can be harmful. Option D is incorrect because taking levothyroxine at bedtime may result in decreased absorption due to interactions with food and other medications.

Similar Questions