Nursing Elites

1. A nurse is reviewing information about advance directives with a newly admitted client. Which statement by the client indicates an understanding of the teaching?

• A. My family can make decisions if I am unable to.
• B. I have a living will that outlines my wishes when I am unable to make a decision.
• C. I can write down my wishes, but they aren't legally binding.
• D. I don't need to worry about this until I’m critically ill.

Correct answer: B

Rationale: Choice B is the correct answer because having a living will is a legal document that outlines a client's wishes when they are unable to make decisions, indicating a good understanding of advance directives. Choice A is incorrect because it doesn't mention a specific document like a living will. Choice C is incorrect because advance directives, like a living will, can be legally binding. Choice D is incorrect because planning for advance directives should ideally be done before a person becomes critically ill.

2. A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse take?

• A. Aspirate before injecting
• B. Massage the site after injecting
• C. Administer the injection in the abdomen
• D. Inject at a 90-degree angle

Correct answer: C

Rationale: The correct action the nurse should take when administering enoxaparin is to inject the medication in the abdomen subcutaneously. This route ensures proper absorption of the medication. Aspiration is not necessary before injecting enoxaparin as it is a subcutaneous injection, not an intramuscular injection. Massaging the site after injecting should be avoided to prevent bruising. Enoxaparin injections are typically given at a 45 to 90-degree angle, not necessarily at a strict 90-degree angle.

3. A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel telling the client, “If you don’t eat, I’ll put restraints on your wrists and feed you.” The nurse should intervene and explain to the AP that this statement constitutes which of the following torts?

• A. Assault
• B. Battery
• C. Malpractice
• D. Negligence

Correct answer: A

Rationale: The correct answer is A: Assault. Assault is the act of threatening a client with harm, such as the threat of using restraints to force-feed the client, even if no physical contact occurs. In this scenario, the statement made by the assistive personnel constitutes assault because it involves the threat of harm. Choice B, Battery, involves actual physical contact without the client's consent, which is not present in the scenario. Choice C, Malpractice, refers to professional negligence or misconduct, not a direct threat to the client. Choice D, Negligence, involves failure to provide reasonable care that results in harm, which is not applicable in this context.

4. A nurse is caring for a client who has been taking haloperidol for several years. Which of the following assessment findings should the nurse recognize as a long-term side effect of this medication?

• A. Lip-smacking
• B. Agranulocytosis
• C. Clang association
• D. Alopecia

Correct answer: A

Rationale: Lip-smacking is a symptom of tardive dyskinesia, a long-term side effect of antipsychotic medications like haloperidol, characterized by involuntary movements of the face and jaw. Agranulocytosis (Choice B) is a rare but serious side effect of some medications, characterized by a dangerously low white blood cell count. Clang association (Choice C) is a thought disorder characterized by the association of words based on sound rather than meaning. Alopecia (Choice D) refers to hair loss, which is not a known long-term side effect of haloperidol.

5. A nurse is caring for a client prescribed gabapentin. Which of the following should the nurse monitor?

• A. Liver function tests
• B. Renal function
• C. Blood glucose levels
• D. Cardiac rhythm

Correct answer: B

Rationale: The correct answer is B: Renal function. Gabapentin is primarily eliminated by the kidneys, so monitoring renal function is essential to ensure the drug is being cleared effectively from the body. Monitoring liver function tests (choice A) is not a priority for gabapentin as it is not primarily metabolized by the liver. Blood glucose levels (choice C) are not directly impacted by gabapentin. Cardiac rhythm (choice D) monitoring is not typically necessary for clients on gabapentin unless they have pre-existing cardiac conditions that may be exacerbated by the medication.

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