Nursing Elites

1. On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse's initial response should be to:

• A. Give the client orientation materials and review the unit rules and regulations.
• B. Introduce him/her and accompany the client to the client's room.
• C. Take the client to the day room and introduce him/her to the other clients.
• D. Ask the nursing assistant to get the client's vital signs and complete the admission search.

Correct answer: B

Rationale: Anxiety is triggered by change that threatens the individual's sense of security. In response to anxiety in clients, the nurse should remain calm, minimize stimuli, and move the client to a calmer, more secure/safe setting. The correct initial response is to introduce the client and accompany them to their room. This approach helps the client feel oriented, safe, and supported. Giving orientation materials or reviewing rules and regulations may overwhelm the client further. Taking the client to the day room and introducing them to other clients could increase anxiety by exposing them to unfamiliar faces. Asking the nursing assistant to get vital signs and complete admission tasks can wait until the client feels more settled and secure in their environment.

2. A client with expressive aphasia is pointing wildly at the bath water but unable to speak. Which response from the nurse is most appropriate?

• A. Is something wrong with the bath water?
• B. Just calm down, we'll finish your bath soon.
• C. Are you trying to tell me something?
• D. Shall I turn on the television?

Correct answer: A

Rationale: A client with expressive aphasia faces difficulty expressing themselves verbally but can understand others. In this scenario, the client's gestures indicate a communication attempt. The nurse's best response is to directly address the potential issue the client is indicating, which is the bath water. Option A acknowledges the client's non-verbal communication and seeks to address their concern. Choices B, C, and D do not directly address the client's attempt to communicate about the bath water, which is the focal point of the interaction.

3. Which nursing intervention is the highest priority for a client at risk for falls in a hospital setting?

• A. Keep all of the side rails up
• B. Review prescribed medications
• C. Complete the "get up and go"? test
• D. Place the bed in the lowest position

Correct answer: D

Rationale: The highest priority nursing intervention for a client at risk for falls in a hospital setting is to place the bed in the lowest position. This action ensures that the client falls the shortest distance, reducing the risk of injury. Keeping all side rails up (Option A) may lead to a fall with injury, as the client might attempt to get over the rail and fall from a higher distance. Reviewing prescribed medications (Option B) is important as certain medications can increase the risk of falling, but it is not the best answer as it is not applicable to all clients. Completing the "get up and go"? test (Option C) can help assess a client's risk for falling but does not directly prevent injury.

4. When placing a patient in the AP position for an X-ray, what position would the patient be in?

• A. Facing the X-ray film.
• B. Right side against the X-ray film.
• C. Left side against the X-ray film.
• D. Facing away from the X-ray film

Correct answer: D

Rationale: The AP position stands for Anteroposterior Projection. When a patient is in the AP position for an X-ray, they are facing away from the X-ray film. This positioning allows for a clear view of the structures being imaged from front to back. Choices A, B, and C are incorrect because the patient is not facing or positioned against the X-ray film in the AP position, but rather facing away from it to capture the necessary diagnostic information.

5. A client is being transferred from a bed to a wheelchair. Which action is essential to maintain client safety in this situation?

• A. Position the wheelchair at the foot of the bed
• B. Maintain a space of at least 12 inches between the wheelchair and the bed
• C. Place the footplates in the lowest position before transferring the client
• D. Lock both wheels on the wheelchair before moving the client

Correct answer: D

Rationale: When transferring a client from a bed to a wheelchair, it is crucial to prioritize client safety. Locking both wheels on the wheelchair before moving the client is essential as it adds stability and prevents the wheelchair from moving unexpectedly during the transfer process. Placing the wheelchair at the foot of the bed allows for easier transfer, but ensuring the wheels are locked is more critical for safety. Maintaining a 12-inch space between the wheelchair and the bed is not as essential as ensuring wheel locks are engaged. While placing the footplates in the lowest position can enhance client comfort, it is not a safety measure that is as critical as securing the wheelchair by locking its wheels before the transfer.

Similar Questions