Nursing Elites

1. What are the key factors in assessing a patient's fall risk?

• A. Assess the patient's age and mobility
• B. Evaluate the patient's medication list for sedatives
• C. Assess the patient's vision and hearing
• D. Check for recent falls and cognitive impairment

Correct answer: A

Rationale: The correct answer is A. Assessing the patient's age and mobility are key factors in determining fall risk. Age can affect balance and reaction time, while mobility influences the patient's stability. Choices B, C, and D are important considerations in assessing a patient's fall risk as well, but age and mobility play a more direct role in determining the patient's susceptibility to falls.

2. A nurse is assisting with the admission of a client who has major depressive disorder. Which of the following communication techniques should the nurse use to establish a trusting relationship with the client?

• A. Offer medical advice
• B. Offer general leads
• C. Ask open-ended questions
• D. Use assertive communication

Correct answer: B

Rationale: In the context of establishing a trusting relationship with a client who has major depressive disorder, offering general leads is the most appropriate communication technique. General leads encourage clients to express themselves by providing subtle prompts or cues, which can help build rapport and trust. Offering medical advice (Choice A) is not suitable as it may come across as imposing and could hinder the establishment of trust. Asking open-ended questions (Choice C) is beneficial for eliciting detailed responses but may not be as effective at initially establishing trust as general leads. Using assertive communication (Choice D) can be perceived as aggressive and intimidating, which is not conducive to building a trusting relationship with a client who has major depressive disorder.

3. What are the complications of untreated deep vein thrombosis (DVT)?

• A. Pulmonary embolism and stroke
• B. Kidney failure and hypertension
• C. Liver failure and electrolyte imbalance
• D. Fluid overload and bradycardia

Correct answer: A

Rationale: Corrected Rationale: Untreated DVT can lead to complications such as pulmonary embolism and stroke. Pulmonary embolism occurs when a blood clot from the leg travels to the lungs, potentially blocking blood flow and causing respiratory distress. Stroke can occur if a blood clot dislodges from the leg veins, travels to the brain, and obstructs a blood vessel, leading to brain tissue damage. Both of these complications are life-threatening if not managed promptly. The other choices (B, C, D) do not represent common complications of untreated DVT and are therefore incorrect.

4. A nurse is providing discharge instructions to a client who has a new prescription for haloperidol. Which of the following adverse effects should the nurse instruct the client to report to the provider?

• A. Weight gain.
• B. Dry mouth.
• C. Sedation.
• D. Shuffling gait.

Correct answer: D

Rationale: The correct answer is D: Shuffling gait. A shuffling gait can indicate extrapyramidal symptoms, a potentially serious side effect of haloperidol. Extrapyramidal symptoms include movement disorders such as dystonia, akathisia, parkinsonism, and tardive dyskinesia. Reporting this symptom promptly is crucial to prevent further complications. Choices A, B, and C are common side effects of haloperidol but are not as urgent or indicative of serious complications compared to a shuffling gait.

5. A client is concerned about extreme fatigue after an acute myocardial infarction. What is the best strategy the nurse can suggest to promote independence in self-care?

• A. Encourage the client to rest and let the healthcare team take over self-care tasks
• B. Instruct the client to gradually resume self-care tasks, with rest periods
• C. Assign assistive personnel to complete self-care tasks for the client
• D. Ask the client's family to assist with self-care

Correct answer: B

Rationale: The best strategy to promote independence in self-care for a client concerned about extreme fatigue after an acute myocardial infarction is to instruct the client to gradually resume self-care tasks, with rest periods. This approach allows the client to regain independence without overexerting. Choice A is incorrect because encouraging the client to rest completely and letting the healthcare team take over self-care tasks may hinder independence. Choice C is incorrect as assigning assistive personnel to complete self-care tasks does not promote the client's independence. Choice D is not the best option as the primary focus should be on empowering the client to perform self-care tasks independently.

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