Nursing Elites

1. Which of the following statements made by a client during an individual therapy session would the nurse most identify as reflecting schizoaffective disorder?

• A. ''I just want to stab myself with this pen.''
• B. ''What's the point in life anyways?''
• C. ''My thoughts are racing because of the conspiracies against me.''
• D. ''I hear voices every day and sometimes see old friends that don't exist.''

Correct answer: C

Rationale: The correct answer is, ''My thoughts are racing because of the conspiracies against me.'' Schizoaffective disorder combines the symptoms of bipolar disorder (mania and depression) with those of schizophrenia (delusions and disturbed thought processes). Racing thoughts are a characteristic symptom of a manic episode, while beliefs in conspiracies indicate paranoia, which are common in schizoaffective disorder. Choices A, B, and D do not specifically align with the symptoms of schizoaffective disorder. Choice A suggests self-harm, which may be seen in various mental health conditions; choice B reflects existential questioning or depression; and choice D describes hallucinations, which are more characteristic of schizophrenia rather than schizoaffective disorder.

2. The mother of a newborn infant with hypospadias asks the nurse why circumcision cannot be performed. Which is the most appropriate response by the nurse?

• A. Circumcision will cause an infection.
• B. Circumcision is not performed in a newborn.
• C. Circumcision will cause difficulty with urination.
• D. Circumcision has been delayed to save tissue for surgical repair.

Correct answer: D

Rationale: The reason circumcision is not performed in a newborn with hypospadias is that the dorsal foreskin tissue will be needed for the surgical repair of hypospadias. Delaying circumcision allows for the preservation of tissue that will be crucial for the corrective surgery. This surgical repair is typically done within the first year of life to minimize the psychological impact on the child. Choices A, B, and C are incorrect as they do not address the specific reason for delaying circumcision in this case.

3. A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure?

• A. Start a peripheral IV line to administer any necessary sedative drugs.
• B. Position the patient sitting upright on the edge of the bed and leaning forward.
• C. Obtain a collection device to hold a reasonable amount of pleural fluid for extraction.
• D. Remove the water pitcher and remind the patient not to eat or drink anything for 6 hours.

Correct answer: B

Rationale: The correct action for the nurse to take in preparing a patient for a thoracentesis is to position the patient sitting upright on the edge of the bed and leaning forward. This position helps fluid accumulate at the lung bases, making it easier to locate and remove. Sedation is not usually required for a thoracentesis, so starting an IV line for sedative drugs is unnecessary. Additionally, there are no restrictions on oral intake before the procedure since the patient is not sedated or unconscious. A large collection device to hold 2 to 3 liters of pleural fluid at one time is excessive as usually only 1000 to 1200 mL of pleural fluid is removed to avoid complications like hypotension, hypoxemia, or pulmonary edema. Therefore, the correct choice is to position the patient upright for the procedure.

4. A client is brought into the emergency department after finishing a course of antibiotics for a urinary tract infection. The client is experiencing dyspnea, chest tightness, and agitation. Her blood pressure is 88/58, she has generalized hives over her body, and her lips and tongue are swollen. After the nurse calls for help, what is the next appropriate action?

• A. Start an IV and administer a 1-liter bolus of Lactated Ringer's solution
• B. Administer 0.3 mg of 1:1000 epinephrine IM
• C. Administer 15 mg diphenhydramine IM
• D. Monitor the client until help arrives

Correct answer: B

Rationale: A client experiencing an anaphylactic reaction will likely present with rash or hives, swelling of the lips, face, or tongue, hypotension, or dyspnea. In this scenario, the client is showing signs of anaphylaxis with dyspnea, chest tightness, hives, hypotension, and swelling of the lips and tongue. The next appropriate action would be to administer 0.3 mg of 1:1000 epinephrine intramuscularly. Epinephrine helps relax the muscles of the airway, improve breathing, and increase oxygenation, which is crucial in managing anaphylaxis. Starting an IV and administering fluids can be important but not the immediate priority. Diphenhydramine may be used as an adjunct therapy but should not delay the administration of epinephrine in the acute phase of anaphylaxis. Monitoring the client without providing immediate treatment can lead to a worsening of the anaphylactic reaction, potentially resulting in a life-threatening situation.

5. A client with asthma has low-pitched wheezes present in the final half of exhalation. One hour later, the client has high-pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client:

• A. Has increased airway obstruction.
• B. Has improved airway obstruction.
• C. Needs to be suctioned.
• D. Exhibits hyperventilation.

Correct answer: B

Rationale: The change from low-pitched wheezes to high-pitched wheezes indicates a shift from larger to smaller airway obstruction, suggesting increased narrowing of the airways. This change signifies a progression or worsening of the airway obstruction. The absence of evidence of secretions does not support the need for suctioning. Hyperventilation is characterized by rapid and deep breathing, which is not indicated by the information provided in the question.

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