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. The client with a diagnosis of hypertension is being taught about lifestyle changes. Which recommendation is most important to include?

• A. Increase sodium intake.
• B. Engage in regular physical activity.
• C. Avoid foods high in fat.
• D. Limit fluid intake to 1 liter per day.

Correct answer: B

Rationale: Engaging in regular physical activity is crucial for individuals with hypertension as it helps lower blood pressure and improve cardiovascular health. Physical activity is known to have a significant impact on reducing hypertension and overall cardiovascular risk. Choice A, increasing sodium intake, is incorrect as reducing sodium is typically recommended for hypertension to help lower blood pressure. Choice C, avoiding foods high in fat, is beneficial for overall health but not the most crucial recommendation for hypertension management. Choice D, limiting fluid intake to 1 liter per day, is not a standard recommendation for hypertension unless advised by a healthcare provider for specific cases. Therefore, the most important recommendation for the client with hypertension is to engage in regular physical activity.

3. How should the nurse assess for cyanosis in a client with dark skin who is in respiratory distress?

• A. Abnormal skin color changes in a client with dark skin cannot be determined
• B. Blanching the soles of the feet in a client with dark skin reveals cyanosis
• C. The lips and mucus membranes of a client with dark skin are dusky in color
• D. Cyanosis in a client with dark skin is seen in the sclera

Correct answer: C

Rationale: Observing the lips and mucous membranes provides a reliable indicator of cyanosis in clients with dark skin tones. Choice A is incorrect because cyanosis can be assessed in clients with dark skin by observing other body areas. Choice B is incorrect as blanching the soles of the feet is not a relevant method for assessing cyanosis. Choice D is incorrect as cyanosis is not typically seen in the sclera in clients with dark skin.

4. The nurse plans to evaluate the effectiveness of several drugs administered by different routes. Arrange the routes of administration from fastest to slowest rate of absorption. 1. Intravenous 2. Sublingual 3. Intramuscular 4. Subcutaneous

• A. 1,2,3,4
• B. 4,3,2,1
• C. 2,4,3,1
• D. 3,4,1,2

Correct answer: A

Rationale: The correct order of routes of administration from fastest to slowest rate of absorption is 1. Intravenous, 2. Sublingual, 3. Intramuscular, 4. Subcutaneous. Intravenous administration provides the fastest absorption as the drug is directly injected into the bloodstream. Sublingual administration allows for rapid absorption through the mucous membranes under the tongue. Intramuscular administration has a slower absorption rate as the drug is injected into the muscle tissue. Subcutaneous administration is the slowest as the drug is injected into the fatty tissue under the skin, leading to a slower absorption compared to the other routes.

5. The nurse assigns an unlicensed assistive personnel (UAP) to feed a client who is at risk for aspiration. What action should the nurse take to ensure safety?

• A. Inform the UAP that suction is available at the bedside.
• B. Instruct the UAP to notify the nurse if the client chokes.
• C. Observe the UAP's ability to implement precautions during feeding.
• D. Ask the UAP about previous experience in performing this skill.

Correct answer: C

Rationale: Observing the UAP's ability to implement precautions during feeding is crucial to ensuring the client's safety, especially when there is a risk of aspiration. This hands-on observation allows the nurse to assess whether the UAP is competent in handling the feeding procedure safely. Informing the UAP about suction availability (Choice A) is important but does not directly assess the UAP's ability during feeding. Instructing the UAP to notify the nurse if the client chokes (Choice B) focuses on reactive measures rather than proactive supervision. Asking about previous experience (Choice D) does not provide real-time information on the UAP's current competency in handling the specific feeding task for the at-risk client.

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