Nursing Elites

1. The nurse is caring for a manic client in the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which of the following actions?

• A. Take the client to the dining room with 1:1 supervision
• B. Inform the client they may go to the dining room when they control their behavior
• C. Hold the meal until the client is able to come out of seclusion
• D. Serve the meal to the client in the seclusion room

Correct answer: D

Rationale: In the scenario described, the manic client is in the seclusion room, and it is most appropriate for the nurse to serve the meal to the client in the seclusion room. This action helps maintain the client's nutritional needs while managing their behavior. Taking the client to the dining room with 1:1 supervision (Choice A) may pose safety risks both for the client and others. Informing the client they may go to the dining room when they control their behavior (Choice B) may not be feasible in a manic state. Holding the meal until the client is able to come out of seclusion (Choice C) can lead to nutritional deficiencies and does not address the immediate need for nutrition during the episode of mania.

2. What are the major risk factors for stroke?

• A. Hypertension, high cholesterol, and smoking
• B. Obesity and lack of exercise
• C. Family history of cardiovascular disease
• D. Age and gender

Correct answer: A

Rationale: The correct answer is A: Hypertension, high cholesterol, and smoking are major risk factors for stroke. These factors contribute to the development of atherosclerosis, which can lead to a stroke. While obesity and lack of exercise are risk factors for cardiovascular diseases, they are not as directly linked to stroke as hypertension, high cholesterol, and smoking. Family history of cardiovascular disease may increase the overall risk of heart problems, but it is not as specific to stroke as the factors listed in option A. Age and gender can influence the risk of stroke, but they are not modifiable risk factors like hypertension, high cholesterol, and smoking, which can be reduced through lifestyle changes.

3. When caring for a client diagnosed with delirium, which condition is most important for the nurse to investigate?

• A. Cancer of any kind
• B. Impaired hearing
• C. Prescription drug intoxication
• D. Heart failure

Correct answer: C

Rationale: When caring for a client diagnosed with delirium, the most important condition for the nurse to investigate is prescription drug intoxication. Delirium can be caused by various factors, and prescription drug intoxication is a common reversible cause. Investigating this factor first is crucial to identify and address the underlying cause promptly. Choices A, B, and D are less likely to be directly associated with delirium compared to prescription drug intoxication. While cancer, impaired hearing, and heart failure can have their complications and effects, they are not typically the primary causes of delirium in a client.

4. A nurse is performing vision testing for a client following a head injury. Which of the following findings should the nurse identify as a problem with pupil accommodation?

• A. Pupils constrict when shifting gaze from near to far
• B. Pupils constrict when shifting gaze from far to near
• C. Lack of change in pupil size when shifting gaze from near to far
• D. Lack of change in pupil size when shifting gaze from far to near

Correct answer: D

Rationale: Pupil accommodation problems are indicated by the lack of change in size when shifting gaze from far to near. The correct answer is D because in pupil accommodation, the pupils should constrict when shifting gaze from far to near in order to adjust for near vision. Choices A and B describe normal responses of pupil constriction when shifting gaze, which do not indicate a problem. Choice C is incorrect as it describes a normal response of pupil size change when shifting gaze from near to far.

5. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include?

• A. Eat a light snack before bedtime.
• B. Stay in bed at least 1 hr if unable to fall asleep.
• C. Take a 1 hr nap during the day.
• D. Perform exercises prior to bedtime.

Correct answer: A

Rationale: The correct answer is to instruct the older adult client to eat a light snack before bedtime. This is beneficial as it helps prevent hunger, which can disrupt sleep. Choice B is incorrect as staying in bed for a prolonged time if unable to fall asleep can lead to frustration and worsen insomnia. Choice C is incorrect as taking a 1-hour nap during the day can interfere with the ability to fall asleep at night. Choice D is incorrect as performing exercises prior to bedtime can increase alertness and make it harder to fall asleep.

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