Nursing Elites

1. How should a healthcare professional assess a patient with a suspected infection?

• A. Monitor temperature and check for elevated white blood cells
• B. Monitor blood pressure and check for fever
• C. Assess for changes in mental status and monitor urine output
• D. Administer antibiotics and monitor for changes in mental status

Correct answer: A

Rationale: When assessing a patient with a suspected infection, it is crucial to monitor temperature and check for elevated white blood cells. Elevated temperature indicates a potential infection, and increased white blood cells are a sign of inflammation and the body's response to an infection. Monitoring blood pressure (choice B) and checking for fever (choice B) are not as specific indicators of infection as monitoring temperature and white blood cell count. Assessing changes in mental status and monitoring urine output (choice C) are important aspects of patient assessment but may not directly indicate a suspected infection. Administering antibiotics (choice D) should only be done after a confirmed diagnosis of a bacterial infection, as unnecessary antibiotic use can lead to antibiotic resistance and other adverse effects.

2. A nurse is reinforcing discharge teaching with a client who has dependent personality disorder. Which of the following instructions should the nurse include in the discharge teaching?

• A. Limit social interactions
• B. Demonstrate assertiveness
• C. Follow a rigid schedule
• D. Perform deep breathing exercises

Correct answer: B

Rationale: The correct answer is B: 'Demonstrate assertiveness.' For clients with dependent personality disorder, assertiveness training is crucial as it helps them become more independent and develop the skills to express their own needs and preferences effectively. Choice A ('Limit social interactions') is incorrect because promoting healthy social interactions is important for individuals with this disorder to build confidence and reduce dependency. Choice C ('Follow a rigid schedule') is incorrect as overly rigid schedules may exacerbate feelings of helplessness and dependence. Choice D ('Perform deep breathing exercises') is not directly related to addressing the core issues of dependent personality disorder, which primarily involve developing self-reliance and assertiveness.

3. A nurse is collecting data from a client who delivered a full-term newborn 16 hours ago. The nurse notes excessive lochia discharge. Which of the following actions should the nurse take first?

• A. Administer pain medication
• B. Perform a fundal massage for the client
• C. Check the baby's heart rate
• D. Apply an ice pack

Correct answer: B

Rationale: The correct action the nurse should take first when noting excessive lochia discharge in a client who delivered a full-term newborn 16 hours ago is to perform a fundal massage. Fundal massage helps stimulate uterine contractions, which in turn reduces bleeding in postpartum clients. Administering pain medication (Choice A) is not the priority in this situation as addressing the excessive lochia discharge is crucial to prevent complications. Checking the baby's heart rate (Choice C) is important but not the first action to manage the mother's condition. Applying an ice pack (Choice D) is not appropriate for managing excessive lochia discharge; fundal massage is the initial intervention to address this issue effectively.

4. What is the best approach to assist a client in performing self-care after an acute myocardial infarction, when the client expresses concern about fatigue?

• A. Provide clear instructions on how to ask for assistance
• B. Gradually resume self-care tasks, focusing on rest periods
• C. Encourage assistive personnel to complete self-care tasks
• D. Encourage the client to remain in bed until fully rested

Correct answer: B

Rationale: The best approach to assist a client in performing self-care after an acute myocardial infarction, especially when the client expresses concern about fatigue, is to gradually resume self-care tasks while focusing on rest periods. This approach allows the client to build confidence in managing their self-care activities while also addressing the issue of fatigue. Choice A is incorrect as it focuses on asking for assistance rather than promoting self-care. Choice C is inappropriate as it suggests delegating the client's self-care tasks to assistive personnel instead of empowering the client. Choice D is incorrect as it can lead to deconditioning and is not conducive to the client's recovery process.

5. The nurse is making a home visit with a client diagnosed with Alzheimer's disease. The client recently started on lorazepam (Ativan) due to increased anxiety. The nurse is cautioning the family about the use of lorazepam (Ativan). The nurse should instruct the family to report which of the following significant side effects to the healthcare provider?

• A. Paradoxical excitement
• B. Headache
• C. Slowing of reflexes
• D. Fatigue

Correct answer: A

Rationale: The correct answer is A, paradoxical excitement. Lorazepam can cause an unexpected response of paradoxical excitement, which should be reported to the healthcare provider. This reaction is characterized by increased anxiety, restlessness, and agitation instead of the expected calming effect. Choices B, C, and D are incorrect because headache, slowing of reflexes, and fatigue are more common side effects of lorazepam and may not warrant immediate reporting unless severe or persistent.

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