Nursing Elites

1. Which of the following is a recommended approach for handling aggressive behavior in a mental health setting?

• A. Encourage the client to express their feelings through physical activity
• B. Avoid making eye contact to prevent escalation
• C. Use pharmacological interventions immediately
• D. Maintain eye contact, offer clear choices, and set boundaries

Correct answer: D

Rationale: The recommended approach for handling aggressive behavior in a mental health setting is to maintain eye contact, offer clear choices, and set boundaries. This approach can help de-escalate the situation by establishing communication and structure. Choice A is incorrect as encouraging physical activity may not be suitable during an aggressive episode. Choice B is incorrect because avoiding eye contact can hinder communication and resolution. Choice C is also incorrect as pharmacological interventions should not be the immediate go-to method for managing aggression unless absolutely necessary.

2. What is the priority action when a patient is experiencing an allergic reaction to a medication?

• A. Monitor the patient's blood pressure every 15 minutes.
• B. Discontinue the medication and notify the healthcare provider.
• C. Administer an antihistamine to reduce symptoms.
• D. Monitor the patient's urine output closely.

Correct answer: B

Rationale: The correct answer is to discontinue the medication and notify the healthcare provider when a patient is experiencing an allergic reaction to a medication. This action is crucial to prevent further harm to the patient. Monitoring blood pressure (choice A) or urine output (choice D) may be important but is not the priority when managing an allergic reaction. Administering an antihistamine (choice C) should only be done after discontinuing the medication and consulting with the healthcare provider.

3. A patient is being taught to use TD nitroglycerin patches to treat angina pectoris. What instructions should be included?

• A. Apply a patch every 12 hours
• B. Apply a new patch every morning
• C. Use it only when symptoms appear
• D. Rotate the application site weekly

Correct answer: B

Rationale: The correct answer is to apply a new patch every morning. Nitroglycerin patches should be applied in the morning and removed at bedtime to provide a 14-hour nitrate-free interval, preventing tolerance development. Choice A is incorrect because applying a patch every 12 hours may lead to tolerance. Choice C is incorrect because nitroglycerin patches are used prophylactically, not just when symptoms appear. Choice D is incorrect because rotating the application site weekly is not necessary; the same site can be used as long as there is no skin irritation.

4. A healthcare provider is reviewing the laboratory report of a client who is receiving heparin therapy for a deep vein thrombosis. Which of the following lab values indicates a therapeutic response to the therapy?

• A. PT of 12 seconds
• B. aPTT of 70 seconds
• C. Platelets of 150,000/mm3
• D. INR of 1.5

Correct answer: B

Rationale: An aPTT of 70 seconds is within the therapeutic range for a client receiving heparin therapy. The activated partial thromboplastin time (aPTT) is the most sensitive test to monitor heparin therapy. A therapeutic aPTT range for a client receiving heparin is usually 1.5 to 2.5 times the control value. Choices A, C, and D are not indicators of a therapeutic response to heparin therapy. PT measures the extrinsic pathway of coagulation and is not specific to monitoring heparin therapy. Platelet count is important to monitor for heparin-induced thrombocytopenia, but it does not indicate the therapeutic response to heparin therapy. INR is used to monitor warfarin therapy, not heparin therapy.

5. A client is vomiting, and a nurse is providing care. Which of the following actions should the nurse take first?

• A. Administer an antiemetic to the client
• B. Notify housekeeping
• C. Prevent the client from aspirating
• D. Provide the client with an emesis basin

Correct answer: C

Rationale: Preventing aspiration is the priority when caring for a client who is vomiting to reduce the risk of pneumonia or other respiratory complications. Aspiration can occur when vomitus enters the airway, leading to respiratory distress. Ensuring the airway is protected during vomiting episodes is essential. Administering an antiemetic (Choice A) can be considered after addressing the immediate risk of aspiration. Notifying housekeeping (Choice B) and providing an emesis basin (Choice D) are important but are secondary to preventing aspiration, which is crucial for the client's safety and well-being.

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