Nursing Elites

1. During the admission assessment of an underweight adolescent with depression on a psychiatric unit, the nurse finds a potassium level of 2.9 mEq/dl. Which finding requires notification to the healthcare provider?

• A. Potassium level of 2.9 mEq/dl.
• B. BP of 110/70 mmHg.
• C. WBC of 10,000 mm³.
• D. Body mass index of 21.

Correct answer: A

Rationale: A potassium level of 2.9 mEq/dl is critically low, indicating hypokalemia, which can lead to serious complications such as cardiac arrhythmias. Prompt notification to the healthcare provider is essential for immediate intervention. Choice B, a blood pressure of 110/70 mmHg, is within the normal range. Choice C, a white blood cell count of 10,000 mm³, is also within normal limits and is not a concerning finding in this context. Choice D, a body mass index of 21, may indicate being underweight but is not as urgent as addressing the critically low potassium level.

2. A healthcare provider is evaluating a client's response to a new antianxiety medication. Which client statement indicates a positive response to the medication?

• A. “I feel more relaxed and less anxious.”
• B. “I am sleeping less and feel more energetic.”
• C. “I have not noticed any changes in my anxiety levels.”
• D. “I have more difficulty concentrating than before.”

Correct answer: A

Rationale: The correct answer is A: “I feel more relaxed and less anxious.” A positive response to antianxiety medication is characterized by reduced anxiety and increased relaxation. Choice B, which mentions sleeping less and feeling more energetic, suggests potential side effects rather than a positive response to the medication. Choice C indicates no change in anxiety levels, which is not indicative of a positive response. Choice D, mentioning difficulty concentrating, is also a sign of a negative response to antianxiety medication as it may suggest cognitive impairment.

3. Which client statement suggests to the nurse that the client is using the defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit?

• A. I am here because the police thought I was doing something wrong
• B. At least I hit the wall instead of hitting the psychiatric aide
• C. I want to be here because I know it is the best psychiatric facility
• D. Don’t believe everything my family tells you, I am not crazy

Correct answer: B

Rationale: The correct answer is B because the client is projecting their aggressive impulses onto an inanimate object, the wall, instead of accepting their own feelings. This statement reflects the defense mechanism of projection. Choice A is not projection; it is an explanation of why the client is there. Choice C indicates acceptance of the facility and does not involve projection. Choice D is a denial statement rather than projection.

4. A client with depression remains in bed most of the day, declines activities, and refuses meals. Which nursing problem has the greatest priority for this client?

• A. Loss of interest in diversional activities.
• B. Social isolation.
• C. Refusal to address nutritional needs.
• D. Low self-esteem.

Correct answer: C

Rationale: The correct answer is C: 'Refusal to address nutritional needs.' In this scenario, the client's refusal to eat and address their nutritional needs poses an immediate threat to their physical health. Without proper nutrition, the client is at risk of malnutrition and its associated complications. While addressing social isolation, low self-esteem, and loss of interest in diversional activities are important aspects of holistic care for a client with depression, ensuring proper nutrition takes precedence due to the critical impact it has on the client's physical well-being. Therefore, the priority is to address the client's refusal to eat and address their nutritional needs to prevent further deterioration of their health.

5. The nurse is completing the admission assessment of an underweight adolescent admitted to the psychiatric unit with a diagnosis of depression. Which finding requires notification to the healthcare provider?

• A. Body mass index of 21
• B. Potassium level of 2.9 mEq/dL
• C. WBC count of 10,000/mm3
• D. Blood pressure of 110/70 mmHg

Correct answer: B

Rationale: The correct answer is B. A potassium level of 2.9 mEq/dL is critically low and requires immediate notification to the healthcare provider as it indicates a potential electrolyte imbalance, which can lead to serious cardiac arrhythmias and other complications. Choices A, C, and D are within normal ranges or not indicative of immediate life-threatening issues. A body mass index of 21 may be considered normal for some individuals, a WBC count of 10,000/mm3 is slightly elevated but not an urgent concern, and a blood pressure of 110/70 mmHg is within normal limits for an adolescent.

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