Nursing Elites

1. The mental health nurse observes that a female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them. Which nursing action will promote trust?

• A. Explain that distrust is related to feeling anxious.
• B. Initiate short, frequent contacts with the client.
• C. Explain that these beliefs are related to her illness.
• D. Offer to keep the belongings at the nurse's desk.

Correct answer: B

Rationale: Initiating short, frequent contacts with the client is the most appropriate action to promote trust. This approach helps build trust and rapport, addressing the client's need for security. By maintaining regular contact, the nurse can provide reassurance and support, which can help alleviate the client's anxiety related to her delusional beliefs. Choice A does not directly address the client's need for trust and security. Choice C focuses on the client's illness but does not actively address building trust. Choice D, offering to keep the belongings at the nurse's desk, may not be well-received by the client and could potentially worsen her anxiety and distrust.

2. A client with coronary artery disease (CAD) is prescribed atorvastatin (Lipitor). Which laboratory value requires immediate intervention?

• A. Total cholesterol of 180 mg/dL.
• B. Low-density lipoprotein (LDL) of 200 mg/dL.
• C. Triglycerides of 150 mg/dL.
• D. High-density lipoprotein (HDL) of 40 mg/dL.

Correct answer: B

Rationale: An LDL level of 200 mg/dL is significantly elevated and requires immediate intervention to reduce the risk of cardiovascular events in a client with coronary artery disease (CAD). High LDL levels contribute to the development and progression of atherosclerosis, which can lead to complications like heart attacks and strokes. Lowering LDL levels is a key goal in managing CAD and preventing further cardiovascular damage. Total cholesterol of 180 mg/dL, triglycerides of 150 mg/dL, and HDL of 40 mg/dL are within acceptable ranges and do not pose an immediate risk that necessitates urgent intervention.

3. A recently widowed middle-aged female client presents to the psychiatric clinic for evaluation and tells the nurse that she has 'little reason to live.' She describes one previous suicidal gesture and admits to having a gun in her home. To maintain the client's confidentiality and to help ensure her safety, which action is best for the nurse to implement?

• A. Encourage the client to remove the gun from her possession.
• B. Notify the client's healthcare provider of the availability of the weapon.
• C. Contact a person of the client's choosing to remove the weapon from the home.
• D. Call the local police department and have the weapon removed from the home.

Correct answer: C

Rationale: In this scenario, it is crucial to maintain the client's confidentiality while ensuring her safety. Contacting a person chosen by the client to remove the weapon from her home is the best course of action. This approach respects the client's autonomy and helps reduce the risk of harm without involving external authorities unnecessarily.

4. A patient with anemia is prescribed ferrous sulfate. What advice should the nurse give regarding the administration of this medication?

• A. Take with dairy products to increase absorption.
• B. Take on an empty stomach for best absorption.
• C. Avoid vitamin C while taking this medication.
• D. Take before bedtime.

Correct answer: B

Rationale: The correct advice for the administration of ferrous sulfate is to take it on an empty stomach for best absorption. This enhances the absorption of iron. If gastrointestinal upset occurs, the medication can be taken with food. Taking ferrous sulfate with dairy products is not recommended as calcium can inhibit iron absorption. Taking it before bedtime is also not recommended. Vitamin C can actually help with the absorption of iron and is often recommended to be taken alongside iron supplements to enhance absorption. Therefore, avoiding vitamin C while taking ferrous sulfate is not correct.

5. The nurse is caring for a client with a history of deep vein thrombosis (DVT) who is receiving warfarin (Coumadin). Which laboratory value should the nurse monitor closely?

• A. Platelet count.
• B. Prothrombin time (PT).
• C. Hemoglobin level.
• D. White blood cell count.

Correct answer: B

Rationale: Prothrombin time (PT) is monitored to ensure therapeutic levels of warfarin and prevent bleeding complications.

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