Nursing Elites

1. The psychiatric nurse is caring for clients in an adolescent unit. Which client requires the nurse's immediate attention?

• A. A 17-year-old client with schizophrenia who is pacing the hallways
• B. An 18-year-old client with antisocial behavior who is being yelled at by other clients
• C. A 16-year-old client with depression who refuses to eat meals
• D. A 15-year-old client with anxiety who is quietly reading in a corner

Correct answer: B

Rationale: The client with antisocial behavior being yelled at by peers may escalate the situation, potentially leading to violence or self-harm. Addressing the situation quickly helps prevent harm and de-escalates the conflict. Choices A, C, and D do not present immediate risks that require urgent intervention compared to the potential danger of a conflict escalating to violence with the client exhibiting antisocial behavior.

2. The client provides three positive responses to the CAGE questionnaire. Which interpretation should the nurse provide?

• A. The CAGE is a tool for identifying substance abuse.
• B. Two positive responses suggest alcohol dependence.
• C. One positive response indicates potential alcohol issues.
• D. All responses must be positive for alcohol dependence.

Correct answer: B

Rationale: The CAGE questionnaire is a widely used screening tool for alcohol dependence. Two or more positive responses suggest a higher likelihood of alcohol dependence. One positive response may indicate potential alcohol issues, but two or more significantly increase the likelihood of dependence. Therefore, choice B is the most appropriate interpretation. Choice A is incorrect because the CAGE questionnaire specifically focuses on alcohol-related issues, not substance abuse in general. Choice C is incorrect as one positive response does not indicate addiction but rather raises a concern. Choice D is incorrect as not all responses need to be positive to suggest alcohol dependence.

3. At 42-weeks gestation, a client refuses induction and desires a natural delivery. What is the most important action for the nurse to take?

• A. Discuss alternative ways to support her birth plan.
• B. Explain the indications for induction in post-term pregnancy.
• C. Discuss the differences between labor with oxytocin and natural labor.
• D. Ask the healthcare provider to discuss the issue with the client.

Correct answer: A

Rationale: The correct answer is to discuss alternative ways to support her birth plan. It is crucial to respect the client's autonomy and desires while ensuring their safety and well-being. Choice B is incorrect because while educating the client about the indications for induction is important, it is not the most immediate action to take in this scenario. Choice C is incorrect as it focuses on comparing labor types rather than supporting the client's birth plan. Choice D is incorrect as the nurse should first engage with the client directly before involving the healthcare provider.

4. A client presents to the clinic with concerns about her left breast. Which assessment finding is most important for the nurse to report?

• A. Multiple firm, round, freely movable masses.
• B. A slight asymmetry of the breasts.
• C. A fixed nodular mass with dimpling of the skin.
• D. Bloody discharge from the nipple.

Correct answer: C

Rationale: The correct answer is C. A fixed nodular mass with dimpling of the skin is concerning for malignancy, such as breast cancer, and should be reported immediately for further evaluation. This finding is more suspicious compared to multiple firm, round, freely movable masses (choice A), which could be benign breast lumps. A slight asymmetry of the breasts (choice B) is a common finding and not as alarming as a fixed nodular mass with dimpling of the skin. Bloody discharge from the nipple (choice D) can be suggestive of other conditions like intraductal papilloma but is not as urgent as the finding described in choice C.

5. A client with pneumonia is receiving intravenous (IV) antibiotics. Which assessment finding indicates that the client's condition is improving?

• A. Client's respiratory rate decreases from 24 to 20 breaths per minute
• B. White blood cell count decreases to normal range
• C. Client reports increased energy levels
• D. Cough becomes productive with green sputum

Correct answer: B

Rationale: A decrease in white blood cell count indicates that the infection is responding to treatment and the client's condition is improving. Monitoring the white blood cell count is a more objective indicator of the body's response to the antibiotics. Choices A, C, and D may also be positive signs, but they are less specific and may vary among individuals. Respiratory rate alone may not be sufficient to indicate improvement, as other factors can influence it. Energy levels and cough characteristics are subjective and may not always correlate with the effectiveness of antibiotic treatment.

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