Nursing Elites

1. A client with a history of seizures is being cared for by a nurse. Which of the following interventions should the nurse prioritize?

• A. Ensure the environment is safe
• B. Administer medications as prescribed
• C. Monitor for signs of infection
• D. Educate the client about triggers

Correct answer: A

Rationale: The nurse should prioritize ensuring the environment is safe for a client with a history of seizures. This intervention is crucial to prevent injury during a seizure. Administering medications as prescribed is important but ensuring a safe environment takes precedence to prevent harm. Monitoring for signs of infection and educating the client about triggers are also essential aspects of care but are not the priority when considering the immediate safety of the client during a seizure.

2. A nurse is assessing a client diagnosed with schizophrenia. The nurse asks the client to interpret the following statement: “When the cat’s away, the mice will play.” The client responds, “The mice come out when the cat is not around.” The nurse should document this finding as:

• A. Echolalia
• B. Associative looseness
• C. Neologisms
• D. Concrete thinking

Correct answer: D

Rationale: The client’s literal interpretation of the statement is an example of concrete thinking, a cognitive symptom often seen in schizophrenia where abstract thinking is impaired. Choice A, Echolalia, is the repetition of words spoken by others, which is not demonstrated in this scenario. Choice B, Associative looseness, refers to a disturbance in the logical progression of thoughts, leading to a disorganized thought process. Choice C, Neologisms, involves creating new words or phrases with unique meanings, which is not evident in the client's response.

3. A nurse is preparing to administer a dose of escitalopram. Which of the following should the nurse assess first?

• A. Mood changes
• B. Blood pressure
• C. Heart rate
• D. Liver function

Correct answer: A

Rationale: The correct answer is to assess for mood changes. When administering escitalopram, it is crucial to evaluate mood changes first because the medication may take some time to demonstrate its full effects on the patient's mood. Assessing blood pressure, heart rate, or liver function is not the priority when administering escitalopram, as these parameters are not directly impacted acutely by this medication.

4. A nurse is monitoring a client who has been receiving intermittent enteral feedings. What should the nurse identify as an intolerance to the feeding?

• A. Increased appetite
• B. Nausea
• C. Weight gain
• D. Regular bowel movements

Correct answer: B

Rationale: Nausea is a common sign of intolerance to enteral feedings. When a client experiences nausea, it can indicate difficulty in tolerating the feeding formula. This intolerance may also manifest as vomiting and dumping syndrome. Choices A, C, and D are incorrect because increased appetite, weight gain, and regular bowel movements are not typical signs of intolerance to enteral feedings.

5. A nurse working in a mobile health clinic is assessing a migrant farm worker. What finding should the nurse identify as a priority?

• A. Report of fatigue and fever
• B. Report of muscle twitching and skin rash
• C. Report of blurred vision
• D. Report of nasal congestion

Correct answer: B

Rationale: Muscle twitching and a skin rash may indicate exposure to pesticides, which requires immediate intervention due to potential toxicity. Fatigue and fever (Choice A) are non-specific symptoms that may indicate various conditions but do not directly indicate pesticide exposure. Blurred vision (Choice C) and nasal congestion (Choice D) are also non-specific symptoms and are less likely to be related to pesticide exposure compared to muscle twitching and a skin rash.

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