Nursing Elites

1. A nurse is assessing a client who was brought to the psychiatric emergency services by law enforcement. The client has disorganized, incoherent speech with loose associations and religious content. The nurse should recognize these signs and symptoms as consistent with which of the following?

• A. Alzheimer's disease
• B. Schizophrenia
• C. Substance intoxication
• D. Depression

Correct answer: B

Rationale: The correct answer is B: Schizophrenia. Disorganized speech, loose associations, and religious delusions are characteristic symptoms of schizophrenia. In this scenario, the client's presentation aligns with positive symptoms of schizophrenia, indicating a severe mental disorder requiring immediate attention. Choice A, Alzheimer's disease, primarily involves cognitive decline and memory impairment, not disorganized speech or religious content. Choice C, Substance intoxication, may present with altered mental status but typically lacks the persistent pattern of symptoms seen in schizophrenia. Choice D, Depression, is associated with a different set of symptoms such as low mood, anhedonia, and changes in appetite or sleep, rather than disorganized speech and loose associations.

2. A nurse is preparing to insert an indwelling urinary catheter into a female client. Which of the following actions should the nurse take?

• A. Inflate the balloon with 10 mL of sterile water prior to insertion
• B. Cleanse the client’s labia and meatus using a front-to-back motion
• C. Ask the client to bear down while inserting the catheter
• D. Inflate the catheter balloon after urine begins to flow

Correct answer: D

Rationale: The correct action for the nurse to take when inserting an indwelling urinary catheter into a female client is to inflate the catheter balloon after urine begins to flow. Inflating the balloon before urine starts flowing can lead to incorrect placement in the urethra, causing trauma. Cleansing the labia and meatus should be done before the insertion, but the crucial step of inflating the balloon should occur after the catheter is correctly placed. Asking the client to bear down is not necessary during catheter insertion.

3. A client is being educated about the use of spironolactone. Which of the following should be included in the teaching?

• A. Avoid potassium-rich foods
• B. Take the medication with food
• C. Monitor for signs of toxicity
• D. Discontinue the medication if potassium levels rise

Correct answer: A

Rationale: The correct answer is A: Avoid potassium-rich foods. Spironolactone can lead to hyperkalemia, a condition characterized by high levels of potassium in the blood. To prevent this complication, clients taking spironolactone should avoid potassium-rich foods. Choice B is incorrect because spironolactone can be taken with or without food. Choice C is not directly related to spironolactone use, as toxicity monitoring is not a specific concern with this medication. Choice D is incorrect because discontinuing the medication solely based on elevated potassium levels may not be necessary; instead, dosage adjustments or potassium restriction are often more appropriate.

4. A nurse is caring for a client prescribed hydromorphone for severe pain. The client's respiratory rate has decreased from 16 breaths per minute to 6. Which of the following medications should the nurse prepare to administer?

• A. Naloxone
• B. Flumazenil
• C. Activated charcoal
• D. Aluminum hydroxide

Correct answer: A

Rationale: Naloxone is the correct answer. Naloxone is the antidote for opioid overdose, including hydromorphone. Opioids can cause respiratory depression, and a significant decrease in respiratory rate from 16 to 6 breaths per minute indicates respiratory compromise. Naloxone should be administered promptly to reverse the effects of the opioid and restore normal respiratory function. Flumazenil (Choice B) is used to reverse the effects of benzodiazepines, not opioids. Activated charcoal (Choice C) is used for gastrointestinal decontamination in cases of overdose with certain substances, but it is not the appropriate intervention for opioid-induced respiratory depression. Aluminum hydroxide (Choice D) is an antacid and has no role in managing opioid overdose or respiratory depression.

5. A client expresses anxiety about an upcoming surgery. What should the nurse do?

• A. Reassure the client that everything will be fine
• B. Ask the client to describe feelings
• C. Tell the client to stay positive
• D. Provide information about the surgery

Correct answer: B

Rationale: Asking the client to describe their feelings is the most appropriate action for the nurse to take. This allows the nurse to understand the specific concerns and anxieties the client is experiencing. Choice A may invalidate the client's feelings and not address the root cause of anxiety. Choice C may come across as dismissive and oversimplified. While providing information about the surgery (Choice D) is important, addressing the client's emotional state is the initial priority in this situation.

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