Nursing Elites

1. Which playroom activities should the nurse organize for a small group of 7-year-old hospitalized children?

• A. Sports and games with rules.
• B. Finger paints and water play.
• C. "Dress-up"? clothes and props.
• D. Chess and television programs

Correct answer: A

Rationale: For 7-year-old children, play serves an important role in developing cooperation, logical reasoning, and social skills. Organizing sports and games with rules is beneficial as it helps children understand the importance of rules, promotes teamwork, and fosters social interactions. Finger paints and water play, while fun, may not target the specific developmental needs of this age group. Similarly, 'Dress-up' clothes and props can encourage imaginative play but may not necessarily promote cooperation and logical reasoning. Chess and television programs are more suited for older children and may not engage 7-year-olds as effectively in developing the desired skills.

2. An older adult patient brought to the emergency department by a family member is wandering outside, saying, "I can't find my way home."? The patient is confused and unable to answer questions. What is the nurse's best action?

• A. Document the patient's mental status and obtain other assessment data from the family member.
• B. Record the patient's answers to questions on the nursing assessment form.
• C. Ask an advanced practice nurse to perform the assessment interview.
• D. Call for a mental health advocate to maintain the patient's rights.

Correct answer: A

Rationale: In this scenario, the patient is confused and unable to answer questions. When the patient is unable to provide information, it is important to use secondary sources such as family members. The nurse's best action is to document the patient's mental status and obtain additional assessment data from the family member. This approach will help gather relevant information about the patient's condition. Asking an advanced practice nurse to perform the assessment interview is not necessary as it is within the staff nurse's scope of practice. Calling for a mental health advocate is also unnecessary at this point as the priority is to assess the patient's condition and gather information from the family member.

3. The patient with migraine headaches has a seizure. After the seizure, which action can you delegate to the nursing assistant?

• A. Document the seizure
• B. Perform neurologic checks
• C. Take the patient's vital signs
• D. Restrain the patient for protection

Correct answer: C

Rationale: After a patient with migraine headaches has a seizure, it is important to assess their vital signs to monitor their condition. This task can be safely delegated to a nursing assistant as it falls within their scope of practice. Documenting the seizure and performing neurologic checks require a higher level of training and should be done by a nurse or healthcare provider. Restraint should never be used as a first-line intervention after a seizure unless there is an immediate threat to the patient's safety, and it should be done following proper protocols and with appropriate training.

4. A patient is in the office for a cyst removal and is very anxious about the procedure. Which of the following descriptions of his respirations would be expected?

• A. Bradypnea
• B. Orthopnea
• C. Tachypnea
• D. Dyspnea

Correct answer: C

Rationale: Tachypnea is defined as a rapid, quick, and shallow respiration rate. When a patient is anxious, they may hyperventilate, leading to tachypnea. Bradypnea (Choice A) is slow breathing, which is not expected in an anxious patient. Orthopnea (Choice B) is difficulty breathing while lying down and is not directly related to anxiety. Dyspnea (Choice D) is shortness of breath, which may not be the primary respiratory pattern seen in an anxious patient undergoing a procedure. Therefore, the correct choice is tachypnea as it aligns with the expected respiratory response to anxiety.

5. Which of the following situations indicates the need to file an incident report?

• A. The neon sign directing parking for visitors has burned out
• B. A nurse must send a syringe pump to maintenance for annual service
• C. A client's blood pressure dropped to 90/55 after receiving a dose of morphine
• D. A client's spouse becomes angry and is asked to leave the premises

Correct answer: D

Rationale: An incident report is necessary for documenting unexpected events that occur in a healthcare setting. Situations that warrant filing an incident report include client accidents, medication errors, security problems, or disruptive behaviors that involve clients, families, or visitors. In this scenario, when a client's spouse displays disruptive behavior and is asked to leave the premises, it is essential to document this incident to ensure a record of the event and its resolution. Choices A, B, and C do not involve disruptive behavior or safety concerns that would require an incident report to be filed.

Similar Questions