Nursing Elites

1. 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.

2. A client with an eating disorder is being treated in a behavioral health unit. Which behavior would the nurse expect to see if the client is responding positively to the treatment?

• A. Adherence to the treatment plan and increased self-care activities.
• B. Increased isolation from others.
• C. Frequent complaining about treatment procedures.
• D. Refusal to eat meals provided by the unit.

Correct answer: A

Rationale: A positive response to treatment for a client with an eating disorder is indicated by adherence to the treatment plan and an increase in self-care activities. These behaviors show that the client is actively engaging in their treatment and taking steps towards recovery. Option B, increased isolation from others, is not indicative of a positive response to treatment as it may suggest withdrawal or avoidance. Option C, frequent complaining about treatment procedures, is not a behavior that signifies a positive response; it may indicate dissatisfaction or discomfort with the treatment. Option D, refusal to eat meals provided by the unit, is also not a positive response as it could suggest continued resistance to treatment and potential worsening of symptoms.

3. A client who has agoraphobia (a fear of crowds) is starting desensitization therapy with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?

• A. Encourage the substitution of positive thoughts for negative ones.
• B. Establish trust by providing a calm, safe environment.
• C. Gradually expose the client to larger crowds.
• D. Encourage deep breathing when anxiety escalates in a crowd.

Correct answer: B

Rationale: Establishing trust by providing a calm and safe environment is crucial for the success of desensitization therapy in clients with agoraphobia. This approach helps the client feel safe and secure, allowing them to gradually confront their fear of crowds. Encouraging positive thoughts (choice A) is beneficial but not as immediately critical as creating a safe space. Progressively exposing the client to larger crowds (choice C) should occur after trust is established and in a controlled manner. Encouraging deep breathing (choice D) is helpful, but creating a safe environment takes precedence to build a foundation for successful desensitization.

4. The occupational health nurse is working with a female employee who was just notified that her child was involved in a motor vehicle accident (MVA) and taken to the hospital. The employee states, “I can’t believe this. What should I do?” Which response is best for the nurse to provide in this crisis?

• A. Tell me what you think should be done.
• B. How serious was the collision?
• C. What do you think you should do?
• D. Call for transportation to the hospital.

Correct answer: D

Rationale: In a crisis situation where the female employee's child is involved in a motor vehicle accident (MVA) and taken to the hospital, the most appropriate response for the nurse is to provide immediate practical assistance. Calling for transportation to the hospital ensures that the employee can quickly reach her child in need of urgent medical attention. The other options (A, B, and C) do not address the immediate need for assistance and may not provide the necessary support required in such a critical situation.

5. When preparing to administer a domestic violence screening tool to a female client, which statement should the RN provide?

• A. If domestic abuse is happening, I need to ask these questions.
• B. State law requires that all clients are screened for domestic violence.
• C. It is essential for us to know if you are experiencing any domestic abuse.
• D. All clients are screened for domestic abuse because it is common in our society.

Correct answer: D

Rationale: The correct answer is D because screening all clients for domestic abuse helps normalize the process and reduces the stigma, encouraging honest responses. Choice A is not the best option as it may come off as accusatory and can deter the client from being open. Choice B, mentioning state law, may create fear or pressure, affecting the client's response. Choice C focuses on the healthcare provider's needs rather than emphasizing the client's well-being, which may not facilitate open communication.

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