Nursing Elites

1. When the nurse identifies what appears to be ventricular tachycardia on the cardiac monitor of a client being evaluated for possible myocardial infarction, the first action the nurse should perform is to

• A. Begin cardiopulmonary resuscitation
• B. Prepare for immediate defibrillation
• C. Notify the 'Code' team and healthcare provider
• D. Assess airway, breathing, and circulation

Correct answer: D

Rationale: The correct first action for the nurse to take when identifying what appears to be ventricular tachycardia in a client being evaluated for possible myocardial infarction is to assess the client's airway, breathing, and circulation. This step is crucial to determine the client's stability and the need for immediate intervention. Beginning cardiopulmonary resuscitation or preparing for immediate defibrillation without first assessing the airway, breathing, and circulation could delay potentially life-saving interventions. Notifying the 'Code' team and healthcare provider should come after ensuring the client's immediate needs are addressed.

2. A client with multiple sclerosis is receiving baclofen (Lioresal). The nurse should monitor the client for which of the following side effects?

• A. Hypertension
• B. Muscle spasms
• C. Drowsiness
• D. Tachycardia

Correct answer: C

Rationale: The correct answer is C: Drowsiness. Baclofen, a muscle relaxant commonly used to treat conditions like multiple sclerosis, can cause drowsiness as a side effect. Monitoring for drowsiness is important to ensure the client's safety and well-being. Choice A, Hypertension, is incorrect because baclofen is not known to cause hypertension. Choice B, Muscle spasms, is not a common side effect of baclofen but rather the symptom it is used to treat. Choice D, Tachycardia, is also incorrect as baclofen is not associated with causing an increase in heart rate.

3. Which organization is primarily responsible for global public health?

• A. World Health Organization (WHO)
• B. Centers for Disease Control and Prevention (CDC)
• C. National Institutes of Health (NIH)
• D. United Nations (UN)

Correct answer: A

Rationale: The correct answer is A: World Health Organization (WHO). The WHO is the primary organization responsible for global public health initiatives, coordinating international health efforts, setting norms and standards, providing technical support, and monitoring health trends. Choices B, C, and D are incorrect because while they play significant roles in health and global affairs, they do not have the primary responsibility for global public health like the WHO does.

4. 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 oneself and accompany the client to their room
• C. Take the client to the day room and introduce them 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: In situations where a client is trembling and fearful upon admission to a psychiatric unit, it is essential to prioritize building trust and reducing anxiety. By introducing oneself and accompanying the client to their room, the nurse can establish a therapeutic relationship, provide a sense of security, and address the client's immediate emotional needs. Choices A, C, and D are not the most appropriate initial responses as they do not directly address the client's emotional state or focus on establishing a supportive relationship.

5. A 23-year-old single client is in the 33rd week of her first pregnancy. She tells the nurse that she has everything ready for the baby and has made plans for the first weeks together at home. Which normal emotional reaction does the nurse recognize?

• A. Acceptance of the pregnancy
• B. Focus on fetal development
• C. Anticipation of the birth
• D. Ambivalence about pregnancy

Correct answer: C

Rationale: The correct answer is C: 'Anticipation of the birth.' In the third trimester, it is common for expectant mothers to feel excited and prepared for the upcoming birth of their baby. This includes making plans for the baby's arrival and the early days at home. Choice A, 'Acceptance of the pregnancy,' may occur earlier in the pregnancy and does not specifically relate to the third trimester. Choice B, 'Focus on fetal development,' is more common in the earlier stages of pregnancy when the mother may be more concerned with the baby's growth and milestones. Choice D, 'Ambivalence about pregnancy,' suggests conflicting feelings which are less likely in this scenario where the client expresses readiness and plans for the baby's arrival.

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