Nursing Elites

1. An adult female client is admitted to the psychiatric unit with a diagnosis of major depression. After 2 weeks of antidepressant medication therapy, the nurse notices the client has more energy, is giving her belongings away to her visitors, and is in an overall better mood. Which intervention is best for the nurse to implement?

• A. Tell the client to keep her belongings because she will need them at discharge
• B. Ask the client if she has had any recent thoughts of harming herself
• C. Reassure the client that the antidepressant drugs are apparently effective
• D. Support the client by telling her what wonderful progress she is making

Correct answer: B

Rationale: In this scenario, the nurse should ask the client if she has had any recent thoughts of harming herself. Sudden mood improvements and behavioral changes, like giving away belongings, can be concerning signs of possible suicidal ideation. Assessing for suicidal thoughts is crucial to ensure the client's safety. Choice A is incorrect as it does not address the potential risk of harm or assess for suicidal ideation. Choice C is incorrect because simply reassuring the client about the effectiveness of antidepressants does not address the immediate concern of suicidal ideation. Choice D is incorrect as it focuses on praising progress without addressing the potential risk of harm the client may pose to herself.

2. A nurse is developing a care plan for a client with chronic pain. What interventions should be included to help manage pain?

• A. Administer pain medication around the clock
• B. Teach relaxation techniques
• C. Encourage physical activity
• D. All of the above

Correct answer: D

Rationale: In managing chronic pain, it is essential to employ a multi-faceted approach. Administering pain medication around the clock helps maintain consistent pain relief. Teaching relaxation techniques such as deep breathing or guided imagery can help reduce muscle tension and promote relaxation, which can alleviate pain. Encouraging physical activity, tailored to the client's abilities, can help improve overall physical functioning and reduce pain perception. Therefore, combining all these interventions (pain medication, relaxation techniques, and physical activity) provides a comprehensive approach to pain management, addressing different aspects of the client's experience with chronic pain. This holistic approach is more effective than using a single intervention alone, making 'All of the above' the correct choice.

3. A client with chronic kidney disease is receiving hemodialysis. Which assessment finding should the nurse report to the healthcare provider immediately?

• A. Decreased urine output
• B. Weight loss of 1 kg
• C. Blood pressure of 150/90 mm Hg
• D. Presence of a bruit over the fistula

Correct answer: C

Rationale: The correct answer is C. An elevated blood pressure in clients with chronic kidney disease undergoing hemodialysis can indicate fluid overload or poor dialysis efficacy and should be reported immediately. This finding could lead to complications such as heart failure or pulmonary edema. Choices A, B, and D are not as critical in this situation. Decreased urine output may be expected due to the kidney disease, a weight loss of 1 kg is within an acceptable range, and the presence of a bruit over the fistula is a common finding in clients undergoing hemodialysis and does not require immediate reporting.

4. A client admitted to the hospital with advanced liver failure related to chronic alcoholism is exhibiting ascites and edema. Which pathophysiological mechanisms should the nurse identify as responsible for the third spacing symptoms? (Select all that apply.)

• A. Portal hypertension.
• B. Sodium and water retention.
• C. Decreased serum albumin.
• D. All of the above

Correct answer: D

Rationale: In advanced liver failure related to chronic alcoholism, ascites and edema occur due to multiple pathophysiological mechanisms. Portal hypertension contributes to the development of ascites by increasing pressure in the portal venous system. Sodium and water retention exacerbate fluid accumulation in the third space. Decreased serum albumin levels lead to reduced oncotic pressure, contributing to the movement of fluid into the interstitial spaces. Abnormal protein metabolism further disrupts fluid balance. Therefore, all of the options (A, B, and C) are correct in this scenario, making choice D the correct answer. Choices A, B, and C alone do not fully explain the comprehensive pathophysiological mechanisms involved in the development of ascites and edema in this clinical context.

5. A client is diagnosed with Angina Pectoris. Which factor in the client's history is likely related to the anginal pain?

• A. Smokes one pack of cigarettes daily
• B. Drinks two beers daily
• C. Works in a job that requires exposure to the sun
• D. Eats while lying in bed

Correct answer: A

Rationale: The correct answer is A: 'Smokes one pack of cigarettes daily.' Smoking is a major risk factor for angina and other cardiovascular diseases due to its impact on blood vessels. Choice B, 'Drinks two beers daily,' is not directly associated with angina pectoris. While excessive alcohol consumption can contribute to heart problems, it is not a primary risk factor for angina. Choice C, 'Works in a job that requires exposure to the sun,' is not typically related to angina pectoris. Sun exposure is more closely linked to skin-related conditions. Choice D, 'Eats while lying in bed,' is also not a common risk factor for angina. While certain eating habits can impact heart health, this specific behavior is not directly associated with angina pectoris.

Similar Questions