Nursing Elites

1. A client on an acute mental health unit reports hearing voices that are stating, "kill your doctor"?. Which of the following actions should the nurse take first?

• A. Encourage the client to participate in group therapy on the unit.
• B. Initiate one-to-one observation of the client.
• C. Focus the client on reality.
• D. Notify the provider of the client's statement.

Correct answer: B

Rationale: When a client experiences command hallucinations, such as being told to harm someone, the priority is ensuring the safety of the client and others. Initiating one-to-one observation allows for close monitoring and intervention to prevent harm. Encouraging participation in group therapy may not be appropriate or safe at this time. Focusing the client on reality may not be effective when experiencing hallucinations, and notifying the provider should come after immediate safety measures have been taken.

2. Which of the following is an example of effective time management?

• A. Always agreeing to others' requests for help
• B. Arranging long meetings to discuss important data
• C. Using multiple forms of technology to communicate or educate others
• D. Working in a secluded area to minimize interruptions

Correct answer: D

Rationale: Effective time management involves strategies that help individuals focus and complete tasks efficiently. Working in a secluded area to minimize interruptions is an example of effective time management as it allows for concentration and productivity without distractions. Choices A, B, and C are not examples of effective time management. Always agreeing to others' requests for help can lead to overcommitment and time mismanagement. Arranging long meetings can be counterproductive as they consume time that could be used for actual work. Using multiple forms of technology, though helpful, can lead to information overload and inefficiency if not managed properly. Therefore, the most effective choice for optimal time management in this scenario is working in a secluded area to minimize interruptions.

3. A 39-year-old woman presents for treatment of excessive vaginal bleeding after giving birth to twins one week ago. Which nursing diagnosis is most appropriate in this situation?

• A. Knowledge Deficit related to post-partum blood loss
• B. Self-Care Deficit related to post-partum neglect
• C. Fluid Volume Deficit related to post-partum hemorrhage
• D. Body Image Disturbance related to body changes after delivery

Correct answer: C

Rationale: The correct nursing diagnosis in this situation is 'Fluid Volume Deficit related to post-partum hemorrhage.' Post-partum hemorrhage can lead to excessive bleeding, putting the client at risk of fluid volume deficit due to the loss of blood volume. This diagnosis is most appropriate as it addresses the immediate concern of fluid loss. 'Knowledge Deficit related to post-partum blood loss' (Choice A) is incorrect as the priority in this case is addressing the physical issue of fluid volume deficit rather than knowledge deficit. 'Self-Care Deficit related to post-partum neglect' (Choice B) is not relevant to the situation described. 'Body Image Disturbance related to body changes after delivery' (Choice D) is not the most appropriate nursing diagnosis in this context where the primary concern is fluid volume deficit due to post-partum hemorrhage.

4. An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action, if recommended by the nurse, will be most helpful in reducing the incidence of lung disease?

• A. Treat workers with pulmonary fibrosis.
• B. Teach about symptoms of lung disease.
• C. Require the use of protective equipment.
• D. Monitor workers for coughing and wheezing.

Correct answer: C

Rationale: Prevention of lung disease requires the use of appropriate protective equipment such as masks to reduce exposure to inhaled dust, which is a significant risk factor for lung disease. Teaching about symptoms of lung disease, treating workers with pulmonary fibrosis, and monitoring for coughing and wheezing are important actions for early recognition and treatment of lung disease. However, the most effective strategy to prevent lung damage in this scenario is to require the use of protective equipment to minimize exposure to harmful substances.

5. A nurse is caring for a client who is post-op day #1 after a total hip replacement. Although the client was alert with a normal affect in the morning, by lunchtime, the nurse notes the client is confused, has slurred speech, and is having trouble with her balance. Her blood glucose level is 48 mg/dl. What is the next action of the nurse?

• A. Contact the physician immediately
• B. Administer a bolus of 50 cc of D20W through the IV
• C. Administer 10 units of regular insulin
• D. Give the client 6 oz. of orange juice

Correct answer: D

Rationale: A client with a blood glucose level of 48 mg/dl is experiencing significant hypoglycemia, as manifested by confusion, balance difficulties, and slurred speech. The nurse should work to correct this situation as rapidly as possible. The first measure that can be performed quickly and will have fast results is to give the client something to eat or drink that contains glucose, such as 6 oz. of orange juice. Administering a bolus of D20W through the IV (Choice B) would be too aggressive and could lead to complications in this scenario. Administering regular insulin (Choice C) would further lower the blood glucose level, worsening the client's symptoms. Contacting the physician (Choice A) is important, but immediate intervention to raise the blood glucose level is crucial to address the client's hypoglycemia.

Similar Questions