Nursing Elites

1. A primary belief of psychiatric mental health nursing is:

• A. Most people have the potential to change and grow.
• B. Every person is worthy of dignity and respect.
• C. Human needs are individual to each person.
• D. Some behaviors have no meaning and cannot be understood.

Correct answer: B

Rationale: The correct answer is that every person is worthy of dignity and respect. This is a fundamental principle in psychiatric mental health nursing, emphasizing the importance of treating individuals with dignity and respect regardless of their condition. This belief forms the basis of establishing a therapeutic nurse-client relationship. Choice A is a positive belief, but the primary focus in psychiatric mental health nursing is on respecting the worth and dignity of each individual. Choice C is related to understanding individual human needs but does not encompass the core value of dignity and respect. Choice D is incorrect as psychiatric nursing emphasizes the importance of interpreting and understanding all behaviors as meaningful expressions of the client's experience.

2. The physician has ordered sodium warfarin (Coumadin) for the client with thrombophlebitis. The order should be entered to administer the medication at:

• A. 900
• B. 1200
• C. 1700
• D. 2100

Correct answer: C

Rationale: Sodium warfarin is typically administered in the late afternoon, around 1700 hours. This timing allows for accurate bleeding times to be drawn in the morning. Administering it at 0900 (choice A) would not align with this schedule and may affect the monitoring of bleeding times. Choice B (1200) is midday, which is not the recommended time for sodium warfarin administration. Choice D (2100) is in the evening, which is also not ideal. Therefore, the correct time for administering sodium warfarin is 1700 (choice C).

3. A client reports hearing voices. What should the nurse do next?

• A. Touch the client to help him return to reality.
• B. Leave the client alone until reality returns.
• C. Ask the client to describe what is happening.
• D. Tell the client there are no voices.

Correct answer: C

Rationale: When a client reports hearing voices, it might indicate hallucinations. It is essential for the nurse to ask the client to describe what is happening to gain a better understanding of the hallucinations. This approach helps in assessing the severity and content of the hallucinations, which can guide further interventions. Touching the client without consent can be intrusive and may escalate the situation, violating the client's personal space. Leaving the client alone may not address the underlying issue of hallucinations and can lead to potential risks if the client is distressed. Telling the client there are no voices denies their experience, invalidates their feelings, and can result in mistrust between the client and the nurse.

4. The child with seizure disorder is being treated with Dilantin (phenytoin). Which of the following statements by the patient's mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy?

• A. "She is very irritable lately."?
• B. "She sleeps quite a bit of the time."?
• C. "Her gums look too big for her teeth."?
• D. "She has gained about 10 pounds in the last 6 months."?

Correct answer: C

Rationale: The correct answer is '"Her gums look too big for her teeth."?' Hyperplasia of the gums is a known side effect associated with Dilantin therapy. Option A, '"She is very irritable lately,"?' is not a typical side effect of Dilantin. Option B, '"She sleeps quite a bit of the time,"?' is a common side effect of Dilantin but not specific to gum hyperplasia. Option D, '"She has gained about 10 pounds in the last 6 months,"?' is not typically associated with Dilantin therapy and is unrelated to the question.

5. Which information should be reported to the state Board of Nursing?

• A. The facility fails to provide literature in both Spanish and English.
• B. The narcotic count has been incorrect on the unit for the past 3 days.
• C. The client fails to receive an itemized account of his bills and services received during his hospital stay.
• D. The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath.

Correct answer: B

Rationale: The correct answer is 'The narcotic count has been incorrect on the unit for the past 3 days.' This information should be reported to the state Board of Nursing as it involves medication errors and potential drug diversion, which are serious issues that fall under the jurisdiction of the Board. Reporting medication discrepancies and errors in narcotic counts is crucial for patient safety and regulatory compliance. Choices A, C, and D involve different types of issues that are not within the direct purview of the Board of Nursing. Providing literature in multiple languages (Choice A), addressing billing practices (Choice C), and resolving staff performance issues (Choice D) should be handled internally or reported to the appropriate departments or authorities, such as the Joint Commission or the charge nurse.

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