Nursing Elites

1. A nurse is creating a plan of care for a newly admitted client who has obsessive-compulsive disorder. Which of the following interventions should the nurse take?

• A. Allow the client enough time to perform rituals
• B. Give the client autonomy in scheduling activities
• C. Discourage the client from exploring irrational fears
• D. Provide negative reinforcement for ritualistic behaviors

Correct answer: A

Rationale: The correct intervention for a client with obsessive-compulsive disorder is to allow the client enough time to perform rituals. This helps manage anxiety and stress in individuals with OCD. Allowing time for rituals can provide a sense of control and reduce distress. Choice B, giving the client autonomy in scheduling activities, may not address the core symptoms of OCD related to rituals and compulsions. Choice C, discouraging the client from exploring irrational fears, goes against the principles of exposure therapy, which is a common treatment for OCD. Choice D, providing negative reinforcement for ritualistic behaviors, is not recommended as it can reinforce the behavior rather than help the client manage it.

2. A client who has a new prescription for alendronate is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should take this medication with a full glass of water before breakfast.
• B. I should take this medication with food to prevent gastrointestinal upset.
• C. I should remain upright for at least 30 minutes after taking this medication.
• D. I should avoid taking this medication with antacids.

Correct answer: C

Rationale: The correct answer is C: "I should remain upright for at least 30 minutes after taking this medication." This statement indicates understanding because clients taking alendronate should remain upright for at least 30 minutes after taking the medication to prevent esophageal irritation. Choice A is incorrect because alendronate should be taken with a full glass of water after waking up, not before breakfast. Choice B is incorrect because alendronate should be taken on an empty stomach, not with food. Choice D is incorrect because alendronate should be taken separately from antacids.

3. What is the primary nursing action for a patient with confusion post-surgery?

• A. Administer oxygen
• B. Reposition the patient
• C. Monitor vital signs
• D. Check oxygen saturation

Correct answer: A

Rationale: Administering oxygen is the primary nursing action for a patient with confusion post-surgery because it helps address any potential hypoxia that may be contributing to the patient's confusion. While repositioning the patient, monitoring vital signs, and checking oxygen saturation are important nursing interventions, administering oxygen takes precedence in ensuring adequate oxygenation levels, which is crucial in managing post-surgery confusion.

4. How should signs of dehydration in an elderly patient be assessed?

• A. Monitor skin turgor
• B. Check for dry mucous membranes
• C. Monitor for sunken eyes
• D. Check capillary refill

Correct answer: A

Rationale: Corrected Rationale: Monitoring skin turgor is a reliable method to assess dehydration in elderly patients. Skin turgor refers to the skin's elasticity or the skin's ability to return to its normal position after being pinched. In dehydration, the skin loses its elasticity, becoming less flexible and slower to return to its original state. Checking for dry mucous membranes (Choice B), monitoring for sunken eyes (Choice C), and checking capillary refill (Choice D) are all relevant assessments in dehydration but are not as specific or sensitive as monitoring skin turgor. Dry mucous membranes and sunken eyes are indicators of dehydration, while capillary refill is more related to circulatory status and less specific to dehydration.

5. A client is 2 hours postoperative following a cholecystectomy. Which of the following interventions should the nurse implement?

• A. Place the client in a supine position
• B. Administer morphine for pain relief
• C. Apply a warm compress to the incision site
• D. Place a pillow under the client's knees

Correct answer: B

Rationale: Administering morphine for pain relief is crucial for postoperative clients following a cholecystectomy to manage pain effectively. Placing the client in a supine position may not be ideal as it can cause discomfort and hinder breathing. Applying a warm compress to the incision site can increase the risk of infection. Placing a pillow under the client's knees is not a priority intervention compared to pain management.

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