Nursing Elites

1. The nurse is preparing to administer an IM dose of vitamin B1 (Thiamine) to a male client experiencing acute alcohol withdrawal and peripheral neuritis. The client belligerently states, 'What do you think you're doing?' How should the nurse respond?

• A. I cannot give you this medication until you calm down.
• B. This shot will help relieve the pain in your feet.
• C. Would you prefer to learn to administer your own shot?
• D. You will feel calmer and less jittery after this shot.

Correct answer: B

Rationale: Choice B is the correct answer because it addresses the client's concern by explaining that the shot will help relieve the pain in his feet, which is a symptom of peripheral neuritis. This response shows empathy and provides the client with a clear benefit of receiving the medication. Choices A, C, and D do not directly address the client's immediate concern about the injection and its purpose, making them less suitable responses. Choice A focuses on the client's behavior rather than the therapeutic effect of the injection. Choice C shifts the responsibility to the client to administer the shot, which may not be appropriate in this situation. Choice D mentions feeling calmer and less jittery, which is not directly related to the client's current complaint of pain in the feet.

2. The nurse is caring for a client who is 2 days post-op following an abdominal surgery. The client reports feeling something 'give way' in the incision site and there is a small amount of bowel protruding from the wound. What action should the nurse take first?

• A. Apply a sterile saline dressing to the wound
• B. Notify the healthcare provider
• C. Administer pain medication
• D. Cover the wound with an abdominal binder

Correct answer: A

Rationale: In this situation, the priority action for the nurse is to apply a sterile saline dressing to the wound. This helps prevent infection and keeps the wound moist, which is crucial in promoting healing and preventing further complications. Option B, notifying the healthcare provider, is important but should come after addressing the wound. Administering pain medication (Option C) may be necessary but is not the first action to take in this emergency situation. Covering the wound with an abdominal binder (Option D) is not appropriate and may cause further harm by applying pressure to the protruding bowel.

3. The nurse offers diet teaching to a female college student who was diagnosed with iron-deficiency anemia following her voluntary adoption of a lacto-vegetarian diet. What nutrients should the nurse suggest this client eat to best meet her nutritional needs while allowing her to adhere to a lacto-vegetarian diet?

• A. Drink whole milk instead of skim milk to enhance the body's production of amino acids
• B. Take vitamin K 10mg PO daily to enhance production of red blood cells
• C. Increase amounts of dark yellow vegetables such as carrots to fortify iron stores
• D. Combine several legumes and grains such as beans and rice to form complete proteins

Correct answer: D

Rationale: Combining legumes and grains ensures the client receives all essential amino acids to form complete proteins, which is crucial in a vegetarian diet. Options A, B, and C are incorrect. Option A is not necessary as there are plant-based sources of essential amino acids in a lacto-vegetarian diet. Option B suggests vitamin K, which is not directly related to enhancing red blood cell production. Option C mentions increasing dark yellow vegetables, which are sources of non-heme iron, but combining legumes and grains is more effective in addressing the protein needs of a lacto-vegetarian.

4. Which assessment finding is most indicative of deep vein thrombosis (DVT) in a client's right leg?

• A. Dorsiflexes the right foot and left on command
• B. A 3 by 5 cm ecchymosis area covering the right calf
• C. Right calf is 3 cm larger in circumference than the left
• D. Bilateral lower extremity has 3+ pitting edema

Correct answer: C

Rationale: The correct answer is C because a significant increase in the circumference of the right calf compared to the left calf is a classic sign of deep vein thrombosis (DVT). Option A is incorrect as dorsiflexing the right foot and left on command does not specifically indicate DVT. Option B describes an ecchymosis area which is more indicative of a bruise rather than DVT. Option D suggests bilateral lower extremity edema, which is not specific to DVT and can be seen in various conditions such as heart failure or renal issues.

5. A male client is admitted to the mental health unit because he experiences panic attacks when driving on the freeway. To attempt to desensitize this fear, what action should the nurse encourage the client to implement?

• A. Watch training videos of people driving in various environments
• B. Begin visualizing himself driving each route to the freeway
• C. Take antianxiety medication two hours before driving on freeways
• D. Get in the car with a support person and drive on a freeway during rush hour

Correct answer: B

Rationale: Visualization techniques, such as visualizing himself driving each route to the freeway, are commonly used in desensitization therapy to help clients gradually overcome their fears. Watching videos of others driving or taking medication do not actively involve the client in facing their fear, which is essential in desensitization therapy. Getting in the car with a support person during rush hour may exacerbate the client's anxiety rather than help in desensitization.

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