Nursing Elites

1. Which intervention should the nurse include in the care plan for a child with tetanus?

• A. Ensure proper hydration
• B. Administer prescribed antibiotics
• C. Monitor vital signs frequently
• D. Minimize the amount of stimuli in the room

Correct answer: D

Rationale: The correct intervention for a child with tetanus is to minimize the amount of stimuli in the room. Tetanus causes severe muscle spasms and sensitivity to stimuli, so reducing stimuli like light, sound, and touch can help prevent painful spasms. While ensuring proper hydration and administering antibiotics are essential components of care, minimizing stimuli is crucial for the child's comfort and safety as it directly addresses the symptoms associated with tetanus.

2. When speaking with a group of teens about chemotherapy side effects for cancer, which side effect would the nurse expect this group to be more interested in discussing?

• A. Mouth sores
• B. Fatigue
• C. Diarrhea
• D. Hair loss

Correct answer: D

Rationale: Teens are more likely to be concerned with hair loss when discussing chemotherapy side effects because it is a visible and emotionally impactful side effect for them. While all the listed side effects are important to consider, hair loss can have a significant impact on a teenager's self-image and emotional well-being, making it a key point of interest for this age group. Mouth sores, fatigue, and diarrhea are also common side effects of chemotherapy, but they may not carry the same level of emotional weight and visibility as hair loss for teens.

3. A client with Alzheimer’s disease is becoming increasingly confused. What action should the nurse take first?

• A. Reorient the client to time and place.
• B. Monitor the client’s vital signs.
• C. Provide the client with calming activities to reduce confusion.
• D. Consult with the healthcare provider about adjusting the client’s medication.

Correct answer: B

Rationale: The correct action for the nurse to take first when a client with Alzheimer’s disease is becoming increasingly confused is to monitor the client’s vital signs (Choice B). Increased confusion in Alzheimer’s disease patients may indicate underlying issues like infection, dehydration, or medication side effects. Monitoring vital signs is crucial in identifying any potential causes of the confusion. Choices A, C, and D are not the priority in this situation. Reorienting the client to time and place (Choice A) can be helpful but is not the first priority. Providing calming activities (Choice C) and consulting with the healthcare provider about medication adjustments (Choice D) may be necessary but should come after assessing the client's vital signs to rule out immediate physical causes of confusion.

4. A client with Alzheimer's disease is exhibiting signs of agitation and aggression. What is the nurse's priority intervention?

• A. Reassure the client and provide emotional support.
• B. Redirect the client to a quiet activity.
• C. Administer a PRN dose of lorazepam.
• D. Apply soft restraints as needed to prevent harm.

Correct answer: B

Rationale: The correct answer is to redirect the client to a quiet activity. This intervention helps reduce agitation and aggression in clients with Alzheimer's disease by providing a distraction and promoting a calming environment. Reassuring the client and providing emotional support (Choice A) can be beneficial but is not the priority in this situation. Administering a PRN dose of lorazepam (Choice C) should not be the first intervention due to the risk of adverse effects and should only be considered if other non-pharmacological interventions are ineffective. Applying restraints (Choice D) should be avoided unless absolutely necessary for the client's safety as it can lead to further distress and is not the initial priority intervention.

5. A client is admitted with a suspected pulmonary embolism (PE). What is the nurse's priority intervention?

• A. Administer anticoagulant therapy as prescribed.
• B. Elevate the head of the bed to 45 degrees.
• C. Check the client's oxygen saturation.
• D. Prepare the client for a CT scan.

Correct answer: D

Rationale: The correct answer is to prepare the client for a CT scan. A CT scan is essential in confirming the presence of a pulmonary embolism (PE) and guiding further treatment. Administering anticoagulant therapy (Choice A) is important in the management of PE, but it is not the priority intervention in this case. Elevating the head of the bed (Choice B) is beneficial for optimizing oxygenation but is not the priority intervention when a PE is suspected. Checking the client's oxygen saturation (Choice C) is important, but obtaining a definitive diagnosis through a CT scan takes precedence in this situation.

Similar Questions