Nursing Elites

1. The physician prescribes captopril (Capoten) 25mg po tid for the client with hypertension. Which of the following adverse reactions can occur with administration of Capoten?

• A. Tinnitus
• B. Persistent cough
• C. Muscle weakness
• D. Diarrhea

Correct answer: B

Rationale: A persistent cough might be related to an adverse reaction to captopril (Capoten). Tinnitus (choice A) and diarrhea (choice D) are not commonly associated adverse reactions of captopril. Muscle weakness (choice C) might occur initially but is not considered a common adverse effect of captopril. Therefore, the correct answer is B, persistent cough, as it is a known adverse reaction to captopril.

2. A client is admitted with a diagnosis of Multiple Drug Use. The nurse should plan care based on knowledge that

• A. Multiple drug use is common.
• B. People might use more than one drug to enhance the effect or relieve withdrawal symptoms.
• C. Combining alcohol and barbiturates can be dangerous due to their combined depressant effects.
• D. Assessment and intervention are more complex with multiple drug use due to the synergistic effects.

Correct answer: B

Rationale: When caring for a client with Multiple Drug Use, it is important to understand that individuals may use more than one drug simultaneously or sequentially to enhance the effect of a particular drug or to relieve withdrawal symptoms. This practice is common among substance users. For example, heroin users may also consume alcohol, marijuana, or benzodiazepines. Combining drugs can have various effects, such as intensifying intoxication or alleviating withdrawal symptoms. It is crucial to recognize that multiple drug use can complicate assessment and intervention due to the diverse effects of different substances on the client's health. Option A is incorrect as multiple drug use is indeed common, not uncommon. Option C is incorrect because combining alcohol and barbiturates can be dangerous due to their combined depressant effects. Option D is incorrect because multiple drug use complicates assessment and intervention rather than making them easier, as the effects of different drugs on the client need to be carefully considered.

3. What should the charge nurse do after overhearing the patient care assistant speaking harshly to the client with dementia?

• A. Change the patient care assistant's assignment
• B. Explore the interaction with the patient care assistant
• C. Discuss the matter with the client's family
• D. Initiate a group session with the patient care assistant

Correct answer: B

Rationale: The best action for the charge nurse to take is to explore the interaction with the patient care assistant. This step allows for clarification of the situation and direct addressing of the issue. Changing the patient care assistant's assignment (choice A) might be necessary, but understanding the situation should come first. Discussing the matter with the client's family (choice C) as an initial step could escalate the situation. Initiating a group session with the patient care assistant (choice D) could be considered later as a preventive measure to avoid similar incidents in the future.

4. Upon arrival at the emergency room, the client presents with severe burns to the left arm, hands, face, and neck. What action should take priority?

• A. Starting an IV
• B. Applying oxygen
• C. Obtaining blood gases
• D. Medicating the client for pain

Correct answer: B

Rationale: In a client with severe burns to the face and neck, airway assessment and supplemental oxygen are crucial. Therefore, applying oxygen is the priority to ensure adequate oxygenation for the client. This intervention takes precedence over other actions to stabilize the client's condition. Starting an IV for fluid resuscitation is the next appropriate step following ensuring oxygenation (Choice A). While pain management is important, it is a secondary priority after ensuring oxygenation and fluid resuscitation, making medicating the client for pain a later intervention (Choice D). Obtaining blood gases (Choice C) is not the immediate priority in this scenario and would typically be ordered by the healthcare provider based on the client's condition and response to initial interventions.

5. Implementing counseling by the nurse specialist for the raped victim represents:

• A. assessment.
• B. crisis intervention.
• C. empathetic concern.
• D. unwarranted intrusion.

Correct answer: B

Rationale: Choice B, crisis intervention, is the correct answer. Counseling by a nurse specialist in a rape crisis situation is a form of crisis intervention, which is part of the Crisis Intervention Model. It aims to provide immediate support and help the victim cope with the traumatic event. Empathetic concern (Choice C) is important but refers more to the nurse's attitude rather than the specific action described. Assessment (Choice A) typically involves gathering information and may have already been done before counseling. Unwarranted intrusion (Choice D) is not applicable here as the counseling is provided to support the victim in a professional and caring manner.

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