Nursing Elites

1. The community mental health nurse is planning to visit four clients with schizophrenia today. Which client should the nurse see first?

• A. The mother who took her children from school because aliens were after them.
• B. The young man who has a history of substance abuse and no telephone.
• C. The newly diagnosed client who needs to be evaluated for medication compliance.
• D. The young woman who believes she is to blame for her recent miscarriage.

Correct answer: A

Rationale: The mother who took her children from school due to delusions of aliens poses a significant risk to her children and herself. This situation requires immediate attention to ensure the safety and well-being of all involved. Choice B is concerning due to the history of substance abuse, but the immediate risk to life and safety as in Choice A takes precedence. Choice C, although important, does not present an immediate danger as the delusional belief of aliens. Choice D, while emotionally distressing, does not pose an immediate threat as the situation described in Choice A.

2. When should the charge nurse intervene based on the observed behavior?

• A. Two staff members are overheard talking about a cure for AIDS outside a client's room.
• B. A hospital transporter is reading a client's history and physical while waiting for an elevator.
• C. A UAP tells a client, 'It's hard to quit drinking but Alcoholics Anonymous helped me.'
• D. Two visitors are discussing a hospitalized client's history of drug abuse in the visitor's lounge.

Correct answer: B

Rationale: The hospital transporter reading a client's history and physical without a legitimate need violates patient confidentiality. This behavior requires immediate intervention to protect the client's privacy and confidentiality rights.

3. The client has received 250 ml of 0.9% normal saline through the IV line in the last hour. The client is now tachypneic and has a pulse rate of 120 beats/minute, with a pulse volume of +4. In addition to reporting the assessment findings to the healthcare provider, what action should the nurse implement?

• A. Discontinue the IV and apply pressure at the site.
• B. Decrease the saline to a keep-open rate.
• C. Increase the rate of the current IV solution.
• D. Change the IV fluid to 0.45% normal saline at the same rate.

Correct answer: B

Rationale: In this scenario, the client is showing signs of fluid overload with tachypnea and a high pulse rate. Decreasing the saline to a keep-open rate is appropriate to prevent further fluid volume excess. This action allows for IV access to be maintained while reducing the fluid administered, helping to manage the symptoms of fluid overload.

4. A client with heart failure is prescribed digoxin (Lanoxin). Which sign of digoxin toxicity should the nurse teach the client to report?

• A. Increased appetite.
• B. Yellow or blurred vision.
• C. Weight gain.
• D. Nasal congestion.

Correct answer: B

Rationale: Yellow or blurred vision is a hallmark sign of digoxin toxicity. Digoxin toxicity can affect various body systems, but visual disturbances, such as yellow or blurred vision, are important signs that the client should report immediately. Other signs like increased appetite, weight gain, or nasal congestion are not typically associated with digoxin toxicity. Prompt reporting of visual disturbances can help prevent further complications associated with digoxin toxicity.

5. A client who participates in a health maintenance organization (HMO) needs a bone marrow transplant for the treatment of breast cancer. The client tells the nurse that she is concerned that her HMO may deny her claim. What action by the nurse best addresses the client's need at this time?

• A. Have the client's healthcare provider write a letter to the HMO explaining the need for the transplant.
• B. Help the client place a call to the HMO to seek information about limitations of coverage.
• C. Encourage the client to contact a lawyer to file a lawsuit against the HMO if necessary.
• D. Have the social worker contact the state board of insurance to register a complaint against the HMO.

Correct answer: B

Rationale: The best action for the nurse to take in this situation is to help the client directly contact the HMO to seek information about limitations of coverage. This approach addresses the client's immediate concerns and clarifies the situation, enabling the client to understand the coverage and potential outcomes regarding the bone marrow transplant. Choice A is not the best option as having the healthcare provider write a letter may not provide immediate clarification on coverage. Choice C is inappropriate as legal action should be considered as a last resort, and choice D involving the state board of insurance is not necessary at this initial stage of addressing the client's concern.

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