Nursing Elites

1. The parents of a child suffering from depression ask the nurse what causes depression in children. Which answer is an appropriate response by the nurse?

• A. The causes of major depression are unknown.
• B. Major affective disorders in parents increase depression in children.
• C. Boys are more likely than girls to be depressed.
• D. The prevalence rate is higher in prepubescent children.

Correct answer: B

Rationale: The correct answer is B because while the exact causes of depression in children are not fully understood, research indicates that children are more likely to experience depression if their parents have a major affective disorder. Choice A is incorrect because it suggests that the causes of major depression are entirely unknown, which is not accurate. Choice C is incorrect as there is no conclusive evidence that boys are more likely than girls to be depressed. Choice D is incorrect as the prevalence rate of depression is not necessarily higher in prepubescent children specifically.

2. A client is receiving intravenous potassium chloride for hypokalemia. Which action should the nurse take to prevent complications during the infusion?

• A. Administer the infusion rapidly
• B. Monitor the infusion site for signs of infiltration
• C. Use a syringe pump for the infusion
• D. Flush the IV line with normal saline before starting the infusion

Correct answer: B

Rationale: The correct action to prevent complications during the infusion of potassium chloride is to monitor the infusion site for signs of infiltration. Rapid administration can lead to adverse effects, including cardiac arrhythmias. Using a syringe pump is not typically necessary for this infusion. Flushing the IV line with normal saline is a good practice but not directly related to preventing complications specifically during the infusion of potassium chloride.

3. Which nursing problem has the highest priority when planning care for a client with Meniere’s disease?

• A. Potential for injury related to vertigo.
• B. Alteration in comfort due to ear pain.
• C. Impaired skin integrity due to immobility.
• D. Anxiety due to fear of falling.

Correct answer: A

Rationale: The correct answer is A. When caring for a client with Meniere’s disease, the highest priority nursing problem is the potential for injury related to vertigo. Meniere’s disease is characterized by symptoms like vertigo, which can increase the risk of falls and injuries. Ensuring the client's safety and preventing falls take precedence over other concerns. Choices B, C, and D are not the highest priority because they do not directly address the immediate risk of harm associated with vertigo and falls.

4. Twelve hours following a unilateral total knee replacement, a client reports being unable to sleep because of severe incisional pain. What is the best initial nursing action?

• A. Administer a prescribed sedative.
• B. Reposition the client for comfort.
• C. Apply ice packs to the surgical site.
• D. Instruct the client in the use of the prescribed patient-controlled analgesia (PCA) pump.

Correct answer: D

Rationale: Instructing the client in the use of the PCA pump is the best initial nursing action for managing severe incisional pain after knee replacement surgery. The PCA pump allows the client to self-administer pain medication effectively, promoting better pain management. Administering a sedative may mask the pain temporarily but doesn't address the root cause. Repositioning the client for comfort or applying ice packs may provide some relief but doesn't address the need for effective pain control as the PCA pump does.

5. An older adult woman with a long history of COPD is admitted with progressive shortness of breath and a persistent cough, is anxious, and is complaining of dry mouth. Which intervention should the nurse implement?

• A. Administer a prescribed sedative
• B. Encourage client to drink water
• C. Apply a high flow venturi mask
• D. Assist her to an upright position

Correct answer: D

Rationale: Assisting the client to an upright position is the most appropriate intervention in this situation. Placing the client upright helps improve lung expansion by reducing diaphragmatic pressure, facilitating better air exchange, and increasing oxygenation. This position also aids in easing breathing efforts. Administering a sedative (Choice A) may further depress the respiratory system, worsening the breathing problem. Encouraging the client to drink water (Choice B) may not directly address the respiratory distress caused by COPD. Applying a high flow venturi mask (Choice C) may be beneficial in some cases but assisting the client to an upright position should be the priority to optimize respiratory function.

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