Nursing Elites

1. An appropriate nursing diagnosis for clients in the acute manic phase of bipolar disorder is:

• A. Risk for injury directed to self
• B. Risk for injury directed to others
• C. Impaired nutrition less than body requirements
• D. Ineffective individual coping

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

2. A healthcare professional is preparing to remove a client’s clogged NG tube prior to re-inserting a new tube. Which of the following actions should the healthcare professional take first?

• A. Assist the client in blowing their nose.
• B. Ask the client to take a deep breath and hold it.
• C. Pinch the proximal end of the tube.
• D. Disconnect the tube from the suction source.

Correct answer: D

Rationale: Correct Answer: Disconnecting the tube from the suction source is the first step in safely removing a clogged NG tube. This action helps prevent any suction-related complications and ensures a smooth transition when removing the tube. Choice A, assisting the client to blow their nose, is not necessary in this situation. Choice B, asking the client to take a deep breath and hold it, is unrelated to the process of removing a clogged NG tube. Choice C, pinching the proximal end of the tube, should only be done after disconnecting the tube from the suction source to prevent the contents from leaking.

3. A nurse is completing an admission assessment on an adolescent client who is vegan. Which breakfast item should the nurse recommend as a protein combination with their diet restriction?

• A. Bagel with cream cheese
• B. Wheat toast with jelly
• C. Oatmeal pancakes with peanut butter
• D. Eggs with tofu bacon

Correct answer: C

Rationale: The correct answer is C: Oatmeal pancakes with peanut butter. For a vegan client, it is important to recommend plant-based protein sources. Oatmeal pancakes with peanut butter offer a good protein combination that aligns with their dietary restriction. Choices A, B, and D are not suitable as they all contain animal-derived products, which are not suitable for a vegan diet.

4. The nurse interprets the statement “Bow down before me! I am the holy mother of Christ! I am the blessed Virgin Mary!” as important in documenting in which of the following areas of mental status examination?

• A. Thought content
• B. Mood
• C. Affect
• D. Attitude

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

5. The nurse’s most unique tool in working with the emotionally ill client is his/her

• A. theoretical knowledge
• B. personality make up
• C. emotional reactions
• D. communication skills

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

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