Nursing Elites

1. When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse's actions during this intervention?

• A. The institution's restraints/seclusion policies
• B. The patient's competence
• C. The patient's voluntary/involuntary status
• D. The patient's nursing care plan

Correct answer: C

Rationale: The correct answer is C because the patient's voluntary or involuntary status should not impact the nurse's actions when using restraints. The use of restraints should be based on the patient's behavior and the need to ensure their safety and the safety of others. Choices A, B, and D are important factors that should influence the nurse's actions. The institution's restraints/seclusion policies provide guidelines on the appropriate use of restraints, the patient's competence helps determine their understanding and ability to control their behavior, and the patient's nursing care plan guides the overall care provided, including the use of restraints if necessary.

2. A charge nurse is teaching new staff members about factors that increase a client's risk of becoming violent. Which of the following risk factors should the nurse include as the best predictor of future violence?

• A. Experiencing delusions.
• B. Male gender.
• C. Previous violent behavior.
• D. A history of being in prison.

Correct answer: C

Rationale: The correct answer is C: Previous violent behavior. This is considered the best predictor of future violent actions as individuals who have a history of violent behavior are more likely to engage in violent acts again. Option A, experiencing delusions, although it can impact behavior, is not as strong of a predictor as past violent behavior. Option B, male gender, is a demographic factor but not as specific or predictive as a history of violence. Option D, a history of being in prison, may indicate past behavior but is not directly linked to future violent actions as a known history of violence.

3. A healthcare professional is assisting with the admission of a client who is experiencing alcohol withdrawal. Which of the following medications should the healthcare professional expect the provider to prescribe for the client?

• A. Haloperidol
• B. Disulfiram
• C. Chlordiazepoxide
• D. Phenobarbital

Correct answer: C

Rationale: Chlordiazepoxide is a benzodiazepine commonly used to manage anxiety and prevent seizures during alcohol withdrawal. Haloperidol (Choice A) is an antipsychotic medication and is not typically used for alcohol withdrawal. Disulfiram (Choice B) is used in the treatment of alcohol use disorder but is not indicated for alcohol withdrawal. Phenobarbital (Choice D) may be used for alcohol withdrawal seizures but is not the first-line medication for managing alcohol withdrawal symptoms.

4. A client with dementia is at risk of falls. Which intervention should the nurse implement to ensure safety?

• A. Use restraints to prevent the client from leaving the bed
• B. Use a bed exit alarm to notify staff when the client tries to leave the bed
• C. Encourage frequent ambulation with assistance
• D. Raise all four side rails to prevent falls

Correct answer: B

Rationale: The correct intervention for a client with dementia at risk of falls is to use a bed exit alarm to notify staff when the client tries to leave the bed. This intervention helps prevent falls while still allowing some freedom of movement. Choice A is incorrect because using restraints can lead to complications and is considered a form of restraint which should be avoided. Choice C is not suitable for a client at high risk of falls due to dementia as it may increase the risk of falls. Choice D is not recommended as raising all four side rails can be considered a form of physical restraint and may not be the best approach to prevent falls in a client with dementia.

5. What are the key interventions for managing pneumonia?

• A. Administer antibiotics and monitor oxygen levels
• B. Administer bronchodilators and encourage deep breathing
• C. Provide fluids and monitor for dehydration
• D. Administer oxygen and provide bed rest

Correct answer: A

Rationale: The correct answer is A: Administer antibiotics and monitor oxygen levels. Antibiotics are essential to treat the infection caused by bacteria in pneumonia, while monitoring oxygen levels helps ensure adequate oxygenation. Administering bronchodilators and encouraging deep breathing, as in choice B, are more commonly associated with managing conditions like asthma or COPD, not pneumonia. Providing fluids and monitoring for dehydration, as in choice C, are important for various conditions but not specific to pneumonia management. Administering oxygen and providing bed rest, as in choice D, may be supportive measures in pneumonia treatment, but the key intervention is administering antibiotics.

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