Nursing Elites

1. The nurse notes that a depressed female client has been more withdrawn and non-communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?

• A. Encourage the client's family to visit more often
• B. Schedule a daily conference with the social worker
• C. Encourage the client to participate in group activities
• D. Engage the client in a non-threatening conversation

Correct answer: D

Rationale: Engaging the client in a non-threatening conversation is crucial as it can help build trust and provide support, addressing the client's withdrawal. This intervention focuses on establishing a therapeutic relationship and giving the client an opportunity to express their feelings. Choices A, B, and C do not directly target the client's need for communication and may not address the underlying issues contributing to her withdrawal. Encouraging the client's family to visit more often (Choice A) may add pressure or discomfort to the client. Scheduling a daily conference with the social worker (Choice B) may not address the client's immediate need for communication. Encouraging the client to participate in group activities (Choice C) may be overwhelming for the client and not address her withdrawal directly.

2. A client diagnosed with a deep vein thrombus (DVT) followed by a diagnosis of pulmonary embolism (PE) is receiving heparin via an infusion pump at a rate of 1400 u/hour. The client tells the nurse, “I wish this medicine would hurry up and dissolve this clot in my lung so that I can go home”. What response is best for the nurse to provide?

• A. Heparin prevents further clot formation, but your risk of bleeding needs to be monitored closely
• B. You seem to be concerned about the length of time it takes for Heparin to dissolve this clot
• C. Let me contact your healthcare provider to discuss the possibility of receiving IV heparin therapy at home
• D. Why are you so anxious to leave the hospital when you know you are not well enough yet?

Correct answer: A

Rationale: The correct response is A: 'Heparin prevents further clot formation, but your risk of bleeding needs to be monitored closely.' Heparin is an anticoagulant that prevents further clot formation, but it does not quickly dissolve existing clots. It is crucial for the nurse to educate the client about the purpose of heparin and the necessity for close monitoring of bleeding risks. Choice B is incorrect as it does not address the misunderstanding about heparin's mechanism of action. Choice C is incorrect as home administration of IV heparin therapy requires careful consideration and should not be suggested without a thorough assessment. Choice D is incorrect as it does not address the client's misconception about heparin's role in dissolving clots and instead focuses on the client's desire to leave the hospital.

3. The healthcare provider is completing a head-to-toe assessment for a client admitted for observation after falling out of a tree. Which finding warrants immediate intervention by the healthcare provider?

• A. Sluggish pupillary response to light
• B. Clear fluid leaking from the nose
• C. Complaint of severe headache
• D. Periorbital ecchymosis of the right eye

Correct answer: B

Rationale: Clear fluid leaking from the nose is concerning for cerebrospinal fluid leakage, which is a medical emergency requiring immediate intervention. Sluggish pupillary response to light may indicate neurological issues but is not as urgent as CSF leakage. Complaint of severe headache is important but not as critical as the possibility of CSF leakage. Periorbital ecchymosis of the right eye could be indicative of trauma but does not pose an immediate threat to the patient's life.

4. The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse to report to the healthcare provider?

• A. Decreased white blood cell count
• B. Pruritus and muscle aches
• C. Elevated liver function tests
• D. Vomiting and diarrhea

Correct answer: C

Rationale: The correct answer is C: Elevated liver function tests. When administering antivirals, especially orally, monitoring liver function tests is crucial as it may indicate liver toxicity. This finding should be reported promptly to the healthcare provider to prevent further complications. Choice A, decreased white blood cell count, may be expected with certain antivirals but is not the most critical finding in this scenario. Pruritus and muscle aches (choice B) are common side effects of antivirals and do not require immediate reporting. Vomiting and diarrhea (choice D) are also common side effects that may not be as concerning as elevated liver function tests.

5. The nurse assesses a 5-year-old child who has been experiencing frequent headaches and vomiting. The nurse notices that the child is lethargic and has a positive Brudzinski sign. Which action should the nurse implement first?

• A. Perform a complete neurological examination
• B. Measure the child’s head circumference
• C. Check the child’s blood glucose level
• D. Notify the healthcare provider immediately

Correct answer: D

Rationale: The correct action for the nurse to implement first is to notify the healthcare provider immediately. The presence of lethargy and a positive Brudzinski sign in a child experiencing frequent headaches and vomiting may indicate a serious condition like meningitis. Prompt notification of the healthcare provider is crucial for timely evaluation and initiation of appropriate treatment. Choice A is incorrect because while a neurological examination may be necessary, it is not the priority when a potentially serious condition like meningitis is suspected. Choice B is incorrect as measuring the child's head circumference is not the most immediate action to take in this situation. Choice C is also incorrect as checking the child's blood glucose level, although important in some cases, is not the priority when a child presents with symptoms suggestive of meningitis.

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