Nursing Elites

1. An adult client is admitted to the emergency department after falling from a ladder. While waiting to have a CT scan, the client requests something for a severe headache. When the nurse offers a prescribed dose of acetaminophen, the client asks for something stronger. Which intervention should the nurse implement?

• A. Administer an anti-inflammatory medication instead
• B. Explain the reason for using only non-narcotics
• C. Consult the healthcare provider about a stronger medication
• D. Administer a stronger medication as requested

Correct answer: B

Rationale: In this scenario, the nurse should explain the reason for using only non-narcotics. Following head trauma, non-narcotic medications such as acetaminophen are preferred to avoid masking symptoms of neurological changes, such as increased intracranial pressure, that could worsen after stronger pain medication. Administering an anti-inflammatory medication (Choice A) may not be appropriate as it may not address the severity of the headache. Consulting the healthcare provider about a stronger medication (Choice C) is important, but the immediate need is to educate the client on the rationale for using non-narcotic medications first. Administering a stronger medication as requested (Choice D) could potentially mask important symptoms and should be avoided in this situation.

2. A client is receiving a blood transfusion and reports feeling chilled and short of breath. What is the nurse's priority action?

• A. Stop the transfusion and notify the healthcare provider.
• B. Administer an antihistamine as prescribed.
• C. Administer a dose of acetaminophen.
• D. Administer a PRN dose of diphenhydramine.

Correct answer: A

Rationale: The correct action for the nurse to take when a client receiving a blood transfusion reports feeling chilled and short of breath is to stop the transfusion immediately and notify the healthcare provider. These symptoms could indicate a transfusion reaction, which can be serious and even life-threatening. Stopping the transfusion is crucial to prevent further adverse reactions, and notifying the healthcare provider ensures timely intervention and appropriate management. Administering antihistamines, acetaminophen, or diphenhydramine is not the priority in this situation and may delay necessary actions to address the potential transfusion reaction.

3. During a neurologic assessment of a client with a suspected stroke, which finding is most concerning?

• A. Unilateral facial droop
• B. Slurred speech
• C. Weakness in one arm
• D. Sudden loss of consciousness

Correct answer: D

Rationale: Sudden loss of consciousness in a client with a suspected stroke is the most concerning finding as it indicates a more severe neurological event, such as brain stem involvement or hemorrhage, requiring immediate intervention. While unilateral facial droop, slurred speech, and weakness in one arm are all common signs of a stroke, sudden loss of consciousness signifies a critical condition that needs urgent attention and evaluation to prevent further complications.

4. A client with hypertension is being educated on lifestyle changes by a nurse. Which recommendation is the most important to reduce blood pressure?

• A. Increase water intake
• B. Avoid alcohol consumption
• C. Exercise regularly
• D. Reduce sodium intake

Correct answer: D

Rationale: Reducing sodium intake is crucial in managing hypertension as high sodium levels can lead to fluid retention and increased blood pressure. While increasing water intake is beneficial for overall health, reducing sodium has a more significant impact on blood pressure. Regular exercise is important for cardiovascular health but does not have as direct an impact on blood pressure as sodium reduction. Avoiding alcohol is also important, but in terms of managing blood pressure, reducing sodium intake takes precedence.

5. An adolescent client with intellectual disability refuses oral hygiene. A behavior modification program is recommended. Which reinforcement is best for the nurse to implement?

• A. Candy for successful oral hygiene tasks.
• B. Tokens for each successful oral hygiene task.
• C. Privilege restrictions for refusing oral hygiene tasks.
• D. Preferred activities or privileges for compliance.

Correct answer: D

Rationale: In this scenario, the best reinforcement for the nurse to implement is preferred activities or privileges for compliance. Positive reinforcement with privileges is effective in encouraging behavior change in adolescents, including those with intellectual disabilities. Choice A (Candy for successful oral hygiene tasks) may not be suitable as it involves providing a sugary reward, which contradicts the goal of oral hygiene. Choice B (Tokens for each successful oral hygiene task) could be effective but may not be as motivating as preferred activities or privileges. Choice C (Privilege restrictions for refusing oral hygiene tasks) focuses on negative reinforcement, which is not as effective as positive reinforcement in behavior modification.

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