Nursing Elites

1. During an admission assessment and interview, which channels of information communication should the healthcare professional be monitoring? Select all that apply.

• A. Auditory
• B. Visual
• C. Written
• D. Tactile

Correct answer: A

Rationale: During an admission assessment and interview, healthcare professionals should monitor auditory, visual, and non-verbal cues. Auditory communication involves listening to the patient's spoken words, tone of voice, and any other sounds they make. Visual communication includes observing the patient's facial expressions, body language, and gestures. Written communication, such as forms or notes, may also provide valuable information. Tactile communication pertains to touch, which is not typically utilized during an admission interview setting. While all channels of communication are important, in this context, auditory cues are particularly crucial for gathering verbal information during the assessment process, making choice A the correct answer. Visual cues and written information are also significant but may not be as critical as auditory cues during an interview. Tactile communication is generally not a primary channel used during a standard admission assessment and interview, hence it is not a key focus in this scenario.

2. The healthcare professional is preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discontinued several days ago. Which medication should also be discontinued?

• A. Alprazolam (Xanax)
• B. Benztropine (Cogentin)
• C. Magnesium (Milk of Magnesia)
• D. Lithium (Lithotabs)

Correct answer: B

Rationale: When an antipsychotic medication is discontinued, medications like Benztropine (Cogentin), which are given to reduce extrapyramidal side effects associated with traditional antipsychotic medications, should also be discontinued. Alprazolam (Xanax) is not directly related to antipsychotic medication use in this context. Magnesium (Milk of Magnesia) is a laxative and not typically indicated for bipolar disorder. Lithium (Lithotabs) is a mood stabilizer commonly used in bipolar disorder, and its discontinuation should be carefully managed under the guidance of a healthcare provider to prevent relapse of symptoms.

3. April, a 10-year-old admitted to inpatient pediatric care, has been getting more and more wound up and is losing self-control in the day room. Time-out does not appear to be an effective tool for April to engage in self-reflection. April’s mother admits to putting her in time-out up to 20 times a day. The nurse recognizes that:

• A. Time-out is an important part of April's baseline discipline.
• B. Time-out is no longer an effective therapeutic measure.
• C. April enjoys time-out and acts out to get some alone time.
• D. Time-out will need to be replaced with seclusion and restraint.

Correct answer: B

Rationale: The correct answer is B: 'Time-out is no longer an effective therapeutic measure.' In this scenario, the excessive use of time-out, up to 20 times a day, indicates that it is no longer effective in helping April self-reflect and control her behavior. Constant use of time-out without achieving the desired outcome suggests the need for alternative therapeutic interventions. Choice A is incorrect because the situation described indicates that time-out is not serving its intended purpose. Choice C is also incorrect as the behavior is not driven by a desire for alone time. Choice D is incorrect and inappropriate as seclusion and restraint should only be considered as a last resort and are not indicated based on the information provided.

4. A client is being educated by a nurse about strategies for a safety plan for intimate partner violence. Which strategies should be included in the safety plan? (Select all that apply)

• A. Have a bag ready that contains extra clothes for self and children.
• B. Establish a code with family and friends to signal violence.
• C. Purchase a gun for protection.
• D. Attend a self-defense course focused on self-protection.

Correct answer: A

Rationale: The correct strategies for a safety plan for a victim of intimate partner violence include having a bag ready with essentials for self and children and establishing a code with family and friends to signal danger. These strategies can help the client prepare for emergencies and seek help discreetly. Purchasing a gun (Choice C) is not a safe or recommended strategy as it can escalate violence and pose more significant risks. Additionally, taking a self-defense course focused on self-protection (Choice D) is important for self-defense, but it should not involve retaliatory actions against the abuser with the intent to cause harm.

5. A teenager who has lost 20 pounds in the last three months is admitted to the hospital with hypotension and tachycardia. The client reports irregular menses and hair loss. Which intervention is most important for the nurse to include in the client’s plan of care?

• A. Initiate caloric and nutritional therapy.
• B. Implement behavioral modification therapy.
• C. Evaluate the client for low self-esteem.
• D. Record daily weights and graph trends.

Correct answer: A

Rationale: The client presents with evidence of anorexia nervosa resulting from self-starvation, which is a life-threatening condition. Providing nutrition and calories is the priority intervention so that the risk of electrolyte imbalance and severe dehydration can be reduced. Behavioral modification therapy (Choice B) may be beneficial in the long term but is not the priority in this acute situation. Evaluating for low self-esteem (Choice C) may be part of the nursing assessment but does not address the immediate life-threatening issues. Recording daily weights and graphing trends (Choice D) is important for monitoring progress but does not address the critical need for nutritional therapy in this case.

Similar Questions