Nursing Elites

1. During an admission history, a client tells a nurse that she is under a lot of stress. Which of the following physiological responses should the nurse expect to increase as a result of stress?

• A. Blood glucose - a common stress response.
• B. Intestinal peristalsis - should decrease due to stress.
• C. Peripheral blood vessels diameter - can vary in response to stress.
• D. Urine output - may vary but not a typical stress response.

Correct answer: A

Rationale: The correct answer is A. Stress typically increases blood glucose levels due to the release of stress hormones like cortisol and adrenaline. Elevated blood glucose helps provide energy for the body to cope with the stressful situation. Choice B is incorrect because intestinal peristalsis, the movement of the intestines, is more likely to decrease under stress due to the 'fight or flight' response. Choice C is incorrect as peripheral blood vessels' diameter may vary in response to stress, with both constriction and dilation possible. Choice D is incorrect as urine output may increase or decrease depending on individual differences and the specific stress response, but it is not a typical or direct physiological response to stress.

2. An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make?

• A. Ask, 'Tell me more about how your friends discourage you.'
• B. Say, 'Your friends should support you, not discourage you.'
• C. Respond, 'It sounds like your friends are not supportive.'
• D. Suggest, 'You need to focus on your treatment plans regardless of your friends.'

Correct answer: A

Rationale: The correct approach for the nurse is to ask the client to elaborate on how their friends discourage them. By doing so, the nurse shows empathy, encourages the client to express their feelings, and gains insight into the situation. This open-ended question can help the nurse understand the specific issues the client is facing and work towards finding solutions collaboratively. Choices B, C, and D do not effectively address the client's concerns or encourage further discussion. Choice B is directive and may come off as judgmental, choice C assumes the friends are not supportive without exploring further, and choice D dismisses the client's feelings and the impact of peer influence.

3. A client who has been experiencing frequent tonic-clonic seizures is being admitted by a nurse. Which of the following actions should the nurse include in the client's plan of care?

• A. Wrap blankets around all four sides of the bed.
• B. Place the client in a padded room.
• C. Maintain the bed in the lowest position.
• D. Ensure the client has a soft mattress.

Correct answer: C

Rationale: Maintaining the bed in the lowest position is crucial in reducing the risk of injury during tonic-clonic seizures. This action helps prevent falls and minimizes potential harm to the client. Wrapping blankets around all four sides of the bed (Choice A) may restrict movement during a seizure and increase the risk of injury. Placing the client in a padded room (Choice B) is not a practical approach in a healthcare setting and may not be feasible. Ensuring the client has a soft mattress (Choice D) alone does not address the safety concerns during seizures, unlike keeping the bed in the lowest position.

4. Which behavior indicates the nurse is using a team approach when caring for a patient who is experiencing alterations in mobility?

• A. Delegates assessment of lung sounds to nursing assistive personnel
• B. Becomes solely responsible for modifying activities of daily living
• C. Consults physical therapy for strengthening exercises in the extremities
• D. Involves respiratory therapy for altered breathing from severe anxiety levels

Correct answer: C

Rationale: Consulting physical therapy for strengthening exercises in the extremities demonstrates a team approach in caring for a patient with mobility issues. Involving other healthcare professionals like physical therapists ensures a comprehensive and specialized approach to address the patient's mobility needs. This collaborative approach benefits the patient by providing specialized interventions. Choices A, B, and D do not exemplify a collaborative team approach. Delegating assessment tasks to nursing assistive personnel (Choice A) may not address the mobility issue directly. Becoming solely responsible for modifying activities of daily living (Choice B) limits the scope of interventions. Involving respiratory therapy for anxiety-related breathing issues (Choice D) addresses a different aspect of care and does not directly target mobility concerns.

5. During auscultation of a client experiencing chest pain worsened by inspiration, a nurse hears a high-pitched scratching sound in both systole and diastole with the diaphragm of the stethoscope placed at the left sternal border. Which of the following heart sounds should the nurse document?

• A. Pericardial friction rub
• B. Murmur
• C. S1 and S2
• D. Bruit

Correct answer: A

Rationale: The correct answer is 'Pericardial friction rub.' A pericardial friction rub is a high-pitched, scratching sound heard in both systole and diastole, which is characteristic of pericardial inflammation. This sound is different from a murmur, which is a swooshing or blowing sound due to turbulent blood flow. S1 and S2 are normal heart sounds, and a bruit is a whooshing sound caused by turbulent blood flow in an artery, not related to pericardial inflammation.

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