Nursing Elites

1. Which nursing action is best when managing a client with severe anxiety?

• A. Maintain a calm manner
• B. Help the client identify thoughts prior to the anxiety
• C. Administer anti-anxiety medication
• D. Initiate seclusion if anxiety escalates

Correct answer: A

Rationale: The correct answer is to maintain a calm manner. When managing a client with severe anxiety, the nurse's calm presence can help the client feel more secure and reduce their anxiety levels. It is essential to create a safe and supportive environment. Helping the client identify thoughts prior to anxiety (choice B) may be beneficial in cognitive-behavioral interventions but may not be the initial best action for severe anxiety. Administering anti-anxiety medication (choice C) should be done by a healthcare provider's order and is not the first-line intervention for managing severe anxiety. Initiating seclusion (choice D) should only be considered as a last resort if the client is at risk of harm to themselves or others, as it can further escalate anxiety and should not be the initial action.

2. A nurse is planning care for a preschool-age child who is in the acute phase of Kawasaki disease. Which of the following interventions should the nurse include in the plan of care?

• A. Administer scheduled doses of acetaminophen every 6 hr.
• B. Monitor the child's cardiac status.
• C. Administer antibiotics via intermittent IV bolus for 24 hr.
• D. Provide stimulation with children of the same age in the playroom.

Correct answer: B

Rationale: Monitoring cardiac status is crucial during the acute phase of Kawasaki disease because of the potential for coronary artery complications. Acetaminophen may be used for fever management but is not the priority intervention. Antibiotics are not indicated as Kawasaki disease is not caused by a bacterial infection. Providing stimulation in the playroom is important for the child's emotional well-being but does not address the immediate physiological concern of cardiac monitoring.

3. What are the key considerations for managing a patient with chronic obstructive pulmonary disease (COPD)?

• A. Airway Management
• B. Oxygen Therapy
• C. Smoking Cessation
• D. Pulmonary Rehabilitation

Correct answer: A

Rationale: The key considerations for managing a patient with COPD include airway management, ensuring adequate oxygenation, promoting smoking cessation, and incorporating pulmonary rehabilitation. While airway management is crucial for maintaining patency and preventing exacerbations, oxygen therapy helps improve oxygen levels in the blood. Smoking cessation is essential to slow down disease progression and reduce exacerbation risk. Pulmonary rehabilitation plays a vital role in enhancing exercise tolerance and overall quality of life for COPD patients. Therefore, while all options are important in managing COPD, airway management is the most critical aspect.

4. What are the key signs of infection after surgery?

• A. Redness
• B. Swelling
• C. Fever
• D. All of the above

Correct answer: D

Rationale: After surgery, key signs of infection include redness, swelling, and fever. Redness and swelling can indicate inflammation at the surgical site, while fever is a systemic response to infection. Choosing 'All of the above' (Option D) is the correct answer because all three signs are commonly associated with post-surgical infections. Options A, B, and C are incorrect as each of them individually can be a sign of infection, but considering all three together provides a more comprehensive assessment for post-operative infection.

5. After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a five-year-old child is admitted to the emergency room. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessments, if observed by the nurse three hours after admission, should be reported to the physician?

• A. The client has slight edema of the eyelids
• B. There is clear fluid draining from the client's right ear
• C. There is some bleeding from the child's lacerations
• D. The client withdraws in response to painful stimuli

Correct answer: B

Rationale: Clear fluid draining from the ear can indicate cerebrospinal fluid leakage, which is a serious concern after a head injury. This leakage can signify a skull fracture or damage to the meninges, potentially leading to infection. Therefore, it should be reported immediately for further evaluation and management. Choices A, C, and D are typical findings after head trauma and are not as urgent as the presence of clear fluid draining from the ear.

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