Nursing Elites

1. When is a depressed client at highest risk for attempting suicide?

• A. Immediately after admission, during one-to-one observation
• B. 7 to 14 days after initiation of antidepressant medication and psychotherapy
• C. Following an angry outburst with family
• D. When the client is removed from the security room

Correct answer: B

Rationale: Depressed clients are at the highest risk of attempting suicide 7 to 14 days after starting antidepressant medication and psychotherapy. During this time, they may start to regain energy but still feel hopeless, which can increase the risk of suicidal ideation and behavior. Choices A, C, and D are incorrect because immediate post-admission, after an angry outburst with family, or when removed from a security room are not specific periods known to be associated with the highest risk of suicide in depressed clients.

2. When assessing a client reporting increased pain after physical therapy, which question should the nurse ask to evaluate the quality of the pain?

• A. Is the pain sharp or dull?
• B. Does the pain radiate to other areas?
• C. Does the pain increase with movement?
• D. Can you rate your pain on a scale of 1 to 10?

Correct answer: A

Rationale: The correct question to ask when assessing the quality of a client's pain is whether the pain is sharp or dull. This helps in understanding the characteristics of the pain being experienced. Choice B, asking if the pain radiates to other areas, focuses more on pain distribution rather than quality. Choice C, inquiring if the pain increases with movement, pertains to aggravating factors rather than pain quality. Choice D, requesting the client to rate pain on a scale of 1 to 10, is related to pain intensity rather than quality.

3. A nurse is caring for an older adult client who becomes agitated when the nurse requests the client’s dentures be removed prior to surgery. Which of the following responses should the nurse make?

• A. You seem worried. Are you concerned someone may see you without your teeth?
• B. Don't worry, it’s just for the surgery.
• C. You need to follow the instructions.
• D. The dentures need to be removed for a reason.

Correct answer: D

Rationale: The correct response is to provide a clear rationale for the request, as stated in option D. By explaining the purpose behind removing the dentures, the nurse helps the client understand the necessity, which can reduce agitation and promote cooperation. Option A demonstrates empathy by addressing the client's potential concern about being seen without dentures but lacks a direct explanation. Option B dismisses the client's feelings with a casual statement that may not address the underlying issue. Option C is authoritarian and lacks empathy, potentially escalating the client's agitation.

4. A female UAP is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment as she has not yet been fitted for a particulate filter mask. Which action should the nurse take?

• A. Advise the UAP to wear a standard face mask to take vital signs, and then get fitted for a filter mask before providing personal care
• B. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client
• C. Instruct the UAP that a standard mask is sufficient for the provision of care for the assigned client
• D. Before changing assignments, determine which staff members have fitted particulate filter masks

Correct answer: D

Rationale: The correct course of action for the nurse is to determine which staff members have already been fitted for particulate filter masks before changing assignments. This ensures safety and compliance with infection control protocols. Option A is incorrect as wearing a standard face mask before being fitted for a filter mask does not address compliance with droplet precautions. Option B is incorrect because the priority is to ensure all staff members have appropriate equipment before providing care. Option C is incorrect as a standard mask may not offer sufficient protection when dealing with clients under droplet precautions.

5. Following surgery on the neck, the client asks the LPN why the head of the bed is up so high. The LPN should tell the client that the high-Fowler position is preferred for what reason?

• A. To reduce strain on the incision
• B. To promote drainage of the wound
• C. To provide stimulation for the client
• D. To reduce edema at the operative site

Correct answer: D

Rationale: The high-Fowler position is preferred after neck surgery to reduce edema at the operative site. Elevating the head of the bed promotes venous return and drainage, aiding in decreasing swelling and fluid accumulation, which helps reduce edema at the operative site. Choice A is incorrect as the main purpose is not solely about reducing strain on the incision. Choice B is incorrect because while drainage may occur, it is not the primary reason for maintaining the high-Fowler position. Choice C is incorrect as providing stimulation is not the primary rationale for positioning the client in high-Fowler.

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