Nursing Elites

1. Which of the following best describes a somatic symptom disorder?

• A. Client experiences sudden onset of symptoms due to stress
• B. Physical manifestations occur due to underlying medical conditions
• C. Client has excessive preoccupation with physical symptoms without a medical cause
• D. Client avoids medical care due to fear of receiving a diagnosis

Correct answer: C

Rationale: The correct answer is C. Somatic symptom disorder is characterized by individuals having excessive preoccupation with physical symptoms that may or may not have an identifiable medical cause. Choice A is incorrect because the sudden onset of symptoms due to stress is more indicative of acute stress reaction. Choice B is incorrect as it describes physical manifestations related to known medical conditions, not somatic symptom disorder. Choice D is incorrect as it relates to health anxiety or illness anxiety disorder, where individuals avoid seeking medical care due to fear of receiving a diagnosis.

2. A nurse is planning care for a client who has dehydration and is receiving a continuous IV infusion of 0.9% sodium chloride. Which of the following interventions should the nurse include in the plan of care?

• A. Monitor the client's intake and output every 6 hours
• B. Administer furosemide to the client
• C. Check the client's IV infusion every 8 hours
• D. Offer the client 240 ml (8 oz) of oral fluids every 4 hours

Correct answer: D

Rationale: Offering the client 240 ml (8 oz) of oral fluids every 4 hours is essential to maintain hydration in a client with dehydration who is receiving continuous IV infusion. This intervention helps ensure an adequate fluid balance. Monitoring the client's intake and output every 6 hours is necessary to assess hydration status and response to treatment. Administering furosemide to the client, choice B, is contraindicated in dehydration as it can further deplete fluid volume. Checking the IV infusion every 8 hours, as in choice C, is important but not as critical as ensuring oral fluid intake to promote hydration.

3. A healthcare provider orders a medication dose three times higher than usual. What is the nurse's first step?

• A. Administer the medication but monitor the patient closely.
• B. Verify the dosage with the prescribing provider.
• C. Administer a lower dose to minimize the risk.
• D. Hold the medication and wait for further clarification.

Correct answer: B

Rationale: The correct answer is B: Verify the dosage with the prescribing provider. When faced with an unusual medication dose, the nurse's initial action should be to confirm the order with the healthcare provider who prescribed it. This step is crucial to prevent medication errors and ensure patient safety. Choices A, C, and D are incorrect because administering the medication without clarification, administering a lower dose without approval, or holding the medication without consulting the provider can all pose risks to the patient's well-being.

4. How is the effectiveness of a diuretic in a patient with heart failure evaluated?

• A. Checking daily weights and lung sounds for improvement
• B. Assessing the patient's blood pressure and urine output
• C. Monitoring for weight loss and reduction in edema
• D. Measuring the patient's heart rate and lung sounds

Correct answer: A

Rationale: The correct way to evaluate the effectiveness of a diuretic in a patient with heart failure is by checking daily weights and lung sounds for improvement. Daily weights help to assess fluid retention changes, while improvement in lung sounds indicates reduced pulmonary congestion. Assessing blood pressure and urine output (Choice B) is important but does not directly evaluate the effectiveness of the diuretic. Monitoring for weight loss and reduction in edema (Choice C) are valid indicators of diuretic effectiveness, but direct observation of daily weights and lung sounds is more specific. Measuring heart rate and lung sounds (Choice D) is relevant but does not directly assess the impact of the diuretic on fluid balance and pulmonary status.

5. After surgery, a patient is experiencing pain. What is the nurse's priority action?

• A. Administer pain medication as prescribed.
• B. Assess the patient's pain using a pain scale.
• C. Offer the patient non-pharmacological pain relief methods.
• D. Reassess the patient's pain level after 30 minutes.

Correct answer: B

Rationale: The correct answer is to assess the patient's pain using a pain scale. This is the priority action because it allows the nurse to obtain an objective measure of the patient's pain intensity. By accurately assessing the pain level, the nurse can determine the appropriate intervention, which may include administering pain medication as prescribed (choice A) or offering non-pharmacological pain relief methods (choice C). Reassessing the patient's pain level after 30 minutes (choice D) is important but comes after the initial assessment to evaluate the effectiveness of the interventions implemented.

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