Nursing Elites

1. An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make?

• A. Ask, 'Tell me more about how your friends discourage you.'
• B. Say, 'Your friends should support you, not discourage you.'
• C. Respond, 'It sounds like your friends are not supportive.'
• D. Suggest, 'You need to focus on your treatment plans regardless of your friends.'

Correct answer: A

Rationale: The correct approach for the nurse is to ask the client to elaborate on how their friends discourage them. By doing so, the nurse shows empathy, encourages the client to express their feelings, and gains insight into the situation. This open-ended question can help the nurse understand the specific issues the client is facing and work towards finding solutions collaboratively. Choices B, C, and D do not effectively address the client's concerns or encourage further discussion. Choice B is directive and may come off as judgmental, choice C assumes the friends are not supportive without exploring further, and choice D dismisses the client's feelings and the impact of peer influence.

2. A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which nursing diagnosis should have priority?

• A. Pain related to ischemia
• B. Risk for altered elimination: constipation
• C. Risk for complication: dysrhythmias
• D. Anxiety related to pain

Correct answer: A

Rationale: The correct answer is A: Pain related to ischemia. This nursing diagnosis should have priority because addressing the pain caused by ischemia is crucial in managing the client's myocardial infarction. Pain management is essential not only for the client's comfort but also for improving outcomes and reducing complications. Choices B, C, and D are not the priority in this scenario. Risk for altered elimination: constipation (Choice B) is not as immediate a concern as managing the client's pain. Risk for complication: dysrhythmias (Choice C) may be a potential concern but addressing the client's pain takes precedence. Anxiety related to pain (Choice D) is important to address but should come after managing the pain itself.

3. The caregiver is teaching parents about accidental poisoning in children. Which point should be emphasized?

• A. Call the Poison Control Center as soon as the situation is identified
• B. Empty the child's mouth in any case of possible poisoning
• C. Have the child move minimally if a toxic substance was inhaled
• D. Do not induce vomiting if the poison is a hydrocarbon

Correct answer: B

Rationale: The correct answer is to emphasize emptying the child's mouth in any case of possible poisoning. This action is crucial to prevent further ingestion of the poisonous substance. Choice A is incorrect because calling the Poison Control Center should be one of the first steps, not waiting until the situation is identified. Choice C is incorrect as moving the child may spread or exacerbate the effects of the toxic substance. Choice D is incorrect because inducing vomiting can be harmful if the poison is a hydrocarbon, as it may lead to aspiration.

4. When caring for an older adult client who becomes agitated when asked to remove dentures before surgery, which of the following responses should the nurse make?

• A. "What worries you about being without your teeth?"
• B. "You need to follow the preoperative instructions and remove your dentures."
• C. "It's important to remove dentures to ensure proper fitting of the mask during anesthesia."
• D. "I will explain why dentures need to be removed before surgery."

Correct answer: A

Rationale: The correct response is to ask the client about their concerns regarding being without their teeth. This approach helps address the client's anxiety and provides insight into the reason for their agitation. Choice B is authoritarian and does not address the client's emotional needs. Choice C focuses on the technical aspect of surgery and does not address the client's emotional state. Choice D implies a one-way communication without addressing the client's feelings or concerns.

5. A client is prescribed a buccal medication. Which of the following client statements indicates that the client understands how to take this medication?

• A. “I will first dissolve the tablet in water.”
• B. “I will insert the tablet between my cheek and teeth.”
• C. “I will place the tablet under my tongue.”
• D. “I will chew the tablet.”

Correct answer: B

Rationale: The correct way to take buccal medications is to insert the tablet between the cheek and gums where it will dissolve slowly. Option A is incorrect because buccal medications are not meant to be dissolved in water. Option C is incorrect as sublingual medications are placed under the tongue. Option D is incorrect because chewing a buccal tablet is not the correct administration method.

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