Nursing Elites

1. A nurse is caring for a client who is being discharged home following a cerebrovascular accident. Which of the following documents should the nurse plan to include with the discharge report?

• A. List of prescribed medications
• B. Potential complications to report
• C. Family contact details
• D. Dietary restrictions

Correct answer: B

Rationale: The correct answer is B: Potential complications to report. Including potential complications in the discharge report is crucial for ensuring proper follow-up care. This information helps the client and their caregivers to be aware of warning signs that may indicate a worsening condition or the need for immediate medical attention. Choices A, C, and D are important aspects of discharge planning, but providing a list of potential complications to report takes precedence as it directly impacts the client's safety and well-being post-discharge.

2. What are the early signs of diabetic ketoacidosis?

• A. Excessive thirst and fruity breath odor
• B. Weight loss and increased urination
• C. Nausea and vomiting
• D. Hypoglycemia and fatigue

Correct answer: A

Rationale: The correct answer is A: Excessive thirst and fruity breath odor. Diabetic ketoacidosis presents with these early signs due to ketone buildup in the body. Choice B, weight loss and increased urination, are more characteristic of uncontrolled diabetes but not specific to diabetic ketoacidosis. Choice C, nausea and vomiting, can occur in diabetic ketoacidosis but are not as early or specific as excessive thirst and fruity breath odor. Choice D, hypoglycemia and fatigue, are not typical signs of diabetic ketoacidosis; rather, diabetic ketoacidosis usually presents with hyperglycemia.

3. A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury for this client?

• A. Use a bed exit alarm system
• B. Raise all four side rails while the client is in bed
• C. Apply soft wrist restraints
• D. Dim the lights in the client's room

Correct answer: A

Rationale: The correct answer is A: Using a bed exit alarm system. A bed exit alarm alerts staff when a client with dementia attempts to leave the bed, reducing the risk of falls. Choice B is incorrect because raising all four side rails can lead to restraint-related injuries and is not recommended. Choice C is incorrect as applying wrist restraints should be avoided due to the risk of injury and decreased mobility. Choice D is incorrect as dimming the lights in the client's room does not directly address the risk of injury associated with dementia.

4. What is the nurse's responsibility when managing a physically assaultive client?

• A. Restrict the client to the room
• B. Place the client under one-to-one supervision
• C. Restore the client's self-control
• D. Clear the area of other clients

Correct answer: C

Rationale: The correct answer is C: Restore the client's self-control. When managing a physically assaultive client, the nurse's responsibility is to help the client regain control over their actions and emotions. This is crucial in preventing harm to themselves and others. Restricting the client to the room (Choice A) may escalate the situation and is not a therapeutic approach. Placing the client under one-to-one supervision (Choice B) is important for safety but does not address the root cause of the behavior. Clearing the area of other clients (Choice D) is necessary for safety but does not directly address the client's self-control. Therefore, the priority in managing an assaultive client is to focus on restoring their self-control.

5. A nurse is caring for a client who has multiple fractures following a motor-vehicle crash. For which of the following client statements should the nurse recommend a referral to an occupational therapist?

• A. I can't brush my teeth properly
• B. I am so frustrated I can't open my milk carton
• C. I can't hold a pencil
• D. I can't write anymore

Correct answer: B

Rationale: The correct answer is B. The client's frustration with opening a milk carton indicates difficulty with activities of daily living, which is a common concern addressed by occupational therapists. Choices A, C, and D are related to fine motor skills, which may also be addressed by an occupational therapist but are not as directly linked to activities of daily living as struggling with tasks like opening containers.

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