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 client with peptic ulcer disease is being taught measures to prevent exacerbation of the condition. Which of the following instructions should the nurse include?

• A. Avoid consuming dairy products
• B. Limit alcohol consumption
• C. Use antacids frequently
• D. Drink coffee to improve digestion

Correct answer: B

Rationale: The correct answer is B: Limit alcohol consumption. Alcohol can irritate the stomach lining and worsen peptic ulcer disease. Avoiding dairy products is not necessary unless the client is lactose intolerant. Using antacids frequently may provide symptomatic relief but does not address the root cause of the condition. Drinking coffee can actually stimulate acid production and potentially aggravate peptic ulcers.

3. A nurse is preparing to administer insulin to a client who has type 1 diabetes mellitus. After drawing up the medication, the nurse accidentally brushes the needle on the counter's surface. Which of the following actions should the nurse take?

• A. Prepare a new dose of insulin injection
• B. Administer the insulin as it is
• C. Wipe the needle with an alcohol swab
• D. Ask the provider for guidance

Correct answer: A

Rationale: The correct action for the nurse to take is to prepare a new dose of insulin injection. Accidentally brushing the needle on a contaminated surface can lead to infection risk. Administering the insulin as it is or just wiping the needle with an alcohol swab would not be sufficient to eliminate the risk of infection. Asking the provider for guidance is not necessary in this situation as the nurse can independently take the appropriate action to ensure patient safety.

4. 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.

5. A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect?

• A. Elevated blood glucose.
• B. Decreased urine output.
• C. Dependent edema.
• D. Jaundice.

Correct answer: C

Rationale: The correct answer is C: Dependent edema. In right-sided heart failure, the heart is unable to effectively pump blood to the lungs for oxygenation, leading to fluid accumulation in the systemic circulation. This fluid backs up in the venous system, causing increased pressure in the veins of the body, resulting in dependent edema, usually starting in the lower extremities. Elevated blood glucose (choice A) is not directly related to right-sided heart failure. Decreased urine output (choice B) may occur in conditions like acute kidney injury but is not a specific finding of right-sided heart failure. Jaundice (choice D) is more commonly associated with liver dysfunction, not typically seen in right-sided heart failure.

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