Nursing Elites

1. When teaching about safety risks for adolescents, what should be included?

• A. Adolescents are more likely to follow rules
• B. Peer influence to participate in high-risk behaviors can lead to injury
• C. Most injuries occur during sports activities
• D. Adolescents are aware of the dangers of substance use

Correct answer: B

Rationale: When educating about safety risks for adolescents, it is crucial to address the impact of peer influence on engaging in high-risk behaviors, which can result in injuries. Choice A is incorrect because adolescents are known to sometimes take risks and not always follow rules. Choice C is incorrect as injuries among adolescents can also happen outside of sports activities. Choice D is incorrect as adolescents may not always be fully aware of the dangers of substance use.

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 healthcare professional is assessing a client for signs of fluid overload. Which of the following findings should the healthcare professional look for?

• A. Weight loss
• B. Decreased blood pressure
• C. Edema
• D. Increased urine output

Correct answer: C

Rationale: Edema is a common sign of fluid overload. When the body retains more fluid than it excretes, it can lead to edema, which is swelling caused by excess fluid trapped in body tissues. Weight gain, not weight loss, is typically associated with fluid overload due to the retained fluids. Decreased blood pressure is more commonly associated with dehydration rather than fluid overload. Increased urine output is a sign of the body trying to eliminate excess fluids, which is contrary to the signs of fluid overload.

4. A nurse is reviewing the laboratory results for a client who has end-stage liver disease. Which of the following findings should the nurse expect?

• A. Elevated albumin
• B. Elevated ammonia
• C. Decreased total bilirubin
• D. Decreased prothrombin time

Correct answer: B

Rationale: In end-stage liver disease, the liver's inability to convert ammonia into urea leads to elevated ammonia levels. Elevated ammonia levels can result in hepatic encephalopathy, a serious complication. Therefore, the correct answer is B. Elevated albumin (Choice A) is not typically seen in end-stage liver disease as liver dysfunction often leads to decreased albumin levels. Decreased total bilirubin (Choice C) is unlikely in end-stage liver disease, as bilirubin levels tend to be elevated due to impaired liver function. Decreased prothrombin time (Choice D) is also not expected in end-stage liver disease, as impaired liver function results in prolonged prothrombin time.

5. A nurse is caring for a client prescribed hydromorphone for severe pain. The client's respiratory rate has decreased from 16 breaths per minute to 6. Which of the following medications should the nurse prepare to administer?

• A. Naloxone
• B. Flumazenil
• C. Activated charcoal
• D. Aluminum hydroxide

Correct answer: A

Rationale: Naloxone is the correct answer. Naloxone is the antidote for opioid overdose, including hydromorphone. Opioids can cause respiratory depression, and a significant decrease in respiratory rate from 16 to 6 breaths per minute indicates respiratory compromise. Naloxone should be administered promptly to reverse the effects of the opioid and restore normal respiratory function. Flumazenil (Choice B) is used to reverse the effects of benzodiazepines, not opioids. Activated charcoal (Choice C) is used for gastrointestinal decontamination in cases of overdose with certain substances, but it is not the appropriate intervention for opioid-induced respiratory depression. Aluminum hydroxide (Choice D) is an antacid and has no role in managing opioid overdose or respiratory depression.

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