Nursing Elites

1. A nurse is planning to administer an oral antibiotic to a client with a communicable disease. The client refuses the medication and tells the nurse that the medication causes abdominal cramping. The nurse responds, 'The medication is needed to prevent the spread of infection, and if you don't take it orally I will have to give it to you in an intramuscular injection.' Which statement accurately describes the nurse's response to the client?

• A. The nurse is justified in administering the medication by way of the intramuscular route because the client has a communicable disease.
• B. The nurse could be charged with assault.
• C. Assault is an intentional threat to bring about harmful or offensive contact. If a nurse threatens to give a client a medication that the client refuses or threatens to give a client an injection without the client's consent, the nurse may be charged with assault. Therefore, the nurse is not justified in administering the medication. Battery is any intentional touching without the client's consent.
• D. The nurse will be justified in administering the medication by the intramuscular route once a prescription has been obtained from the health care provider.

Correct answer: C

Rationale: The correct answer explains the concept of assault, which is an intentional threat to bring about harmful or offensive contact. In the scenario provided, the nurse's statement about administering the medication via an intramuscular injection without the client's consent constitutes a threat, potentially falling under the definition of assault. Choice A is incorrect because the nurse's action is not automatically justified solely by the client having a communicable disease. Choice D is also incorrect because even with a prescription, the nurse cannot administer the medication without the client's consent. Choice C provides a detailed explanation distinguishing assault from battery, which helps in understanding the legal implications of the nurse's response in this situation.

2. A client with dumping syndrome should ___________ while a client with GERD should ___________.

• A. lie down 1 hour after meals; sit up at least 30 minutes after meals
• B. sit up 1 hour after meals; lie flat 30 minutes after meals
• C. sit up after meals; sit up after meals
• D. lie down after meals; lie down after meals

Correct answer: A

Rationale: Clients with dumping syndrome should lie down after eating to decrease the symptoms of dumping syndrome, which include rapid gastric emptying leading to various gastrointestinal symptoms. On the other hand, clients with GERD should sit up at least 30 minutes after meals to prevent the backflow of stomach acid into the esophagus. This position helps reduce symptoms by allowing gravity to keep the stomach contents in place, minimizing the chances of reflux. Therefore, the correct answer is to lie down 1 hour after eating for dumping syndrome and to sit up at least 30 minutes after eating for GERD. Choices B, C, and D are incorrect because they do not accurately reflect the appropriate positioning for each condition.

3. During shift change, a nurse is giving report to the oncoming LPN. Which of these is an inappropriate way to give shift report?

• A. The nurse gives report to the oncoming LPN, checking a wound vac and dressing together.
• B. The nurse reports in SBAR format, noting that the client was noncompliant with their diet during the shift.
• C. The nurse reports in the hallway, in SBAR format, and alerts the oncoming LPN about how rude the client was throughout the shift.
• D. The nurse reports at bedside with the oncoming LPN and discusses the client's concerns after the chart has been reviewed.

Correct answer: C

Rationale: The correct answer is 'The nurse reports in the hallway, in SBAR format, and alerts the oncoming LPN about how rude the client was throughout the shift.' This choice is inappropriate because shift report should be given at the bedside, in SBAR format, and in an objective way. It is important to maintain professionalism and focus on the client's condition and care needs, rather than personal opinions or subjective comments. Reporting in the hallway may compromise patient privacy and confidentiality. Choices A, B, and D demonstrate appropriate ways of giving shift report by focusing on relevant information, using SBAR format, and discussing client concerns after reviewing the chart, which promotes effective communication and continuity of care.

4. Which of the following might be an appropriate nursing diagnosis for an epileptic client?

• A. Dysreflexia
• B. Risk for Injury
• C. Urinary Retention
• D. Unbalanced Nutrition

Correct answer: B

Rationale: The correct nursing diagnosis for an epileptic client would be 'Risk for Injury' as the client is prone to injuries during seizure activity, such as head trauma from falls. Epilepsy does not typically cause dysreflexia. While urinary retention may occur during or after a seizure, it is not a common nursing diagnosis related to epilepsy. 'Unbalanced Nutrition' is not a priority nursing diagnosis for an epileptic client compared to the immediate risk of injury during seizures.

5. How many temporary teeth should the nurse expect to find in a 5-year-old client's mouth?

• A. up to 10
• B. up to 15
• C. up to 20
• D. up to 32

Correct answer: C

Rationale: A 5-year-old child can have up to 20 temporary (deciduous or baby) teeth. The first tooth usually erupts by age 6 months, and the last by age 30 months. All temporary teeth are usually shed between 6 and 13 years of age. Therefore, a 5-year-old child should have up to 20 temporary teeth. The correct answer is 'up to 20.' Choices A, B, and D are incorrect because the correct number of temporary teeth in a 5-year-old child's mouth is up to 20, not 10, 15, or 32.

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