Nursing Elites

1. Which response would the nurse make to a client with borderline personality disorder who receives the wrong tray for lunch and becomes upset at the dietary staff regarding this mistake?

• A. 'Getting angry is not appropriate; let's address this calmly.''
• B. ''Yelling is not acceptable and won't help us resolve this issue.''
• C. 'You must eat the first tray of food, and then I'll get another tray for you.''
• D. 'It must be frustrating to get the wrong tray. I'll order another tray for you.''

Correct answer: D

Rationale: The most appropriate response from the nurse would be, ''It must be frustrating to get the wrong tray. I'll order another tray for you.'' When interacting with clients with borderline personality disorder, it is crucial for nurses to acknowledge the client's emotions empathetically and provide constructive solutions. While expressing anger is understandable, guiding the client towards a more constructive approach is essential. Yelling is not a helpful way to address the situation and threatening seclusion is inappropriate. Additionally, instructing the client to eat the first tray before receiving another one is punitive and disregards the client's preferences and rights.

2. A client comes into the emergency room and asks to see a doctor. He is anxious, visibly upset, and keeps looking behind him to the waiting room. When the nurse asks his chief complaint, he says, 'My roommate is trying to kill me.' Which of the following is the most appropriate initial response of the nurse?

• A. Just wait here and I will notify security.
• B. I'm going to speak with the physician about getting some medication that may help you.
• C. Why is your roommate trying to kill you?
• D. Have you called the police to report this?

Correct answer: C

Rationale: Upon initial assessment of a client who appears anxious and upset, with claims that need further exploration, the nurse's initial response should be to gather more information about the situation. By asking 'Why is your roommate trying to kill you?' the nurse shows empathy while trying to understand the patient's perspective. This open-ended question allows the nurse to assess the situation comprehensively. Options A and D jump to conclusions or suggest actions without understanding the situation. Option B focuses solely on medication without addressing the underlying issue. It is crucial to assess the situation further before taking any action or providing treatment.

3. The nurse is preparing to administer 10 mL of liquid potassium chloride through a feeding tube, followed by 10 mL of liquid acetaminophen. Which action should the nurse include in this procedure?

• A. Dilute each of the medications with sterile water prior to administration.
• B. Mix the medications in one syringe before opening the feeding tube.
• C. Administer water between the doses of the two liquid medications.
• D. Withdraw any fluid from the tube before instilling each medication.

Correct answer: C

Rationale: Water should be instilled into the feeding tube between administering the two medications to maintain the patency of the feeding tube and ensure that the total dose of medication enters the stomach and does not remain in the tube. These liquid medications do not need to be diluted when administered via a feeding tube. Mixing the medications in one syringe can lead to interactions or alterations in the medications' properties. Withdrawing any fluid from the tube before instilling each medication can cause inaccurate dosing and incomplete administration. Therefore, the correct action is to administer water between the doses of the two liquid medications to ensure proper delivery and avoid any complications.

4. Which of the following outcomes is most appropriate during the crisis stage of caring for a victim of domestic violence?

• A. The client will verbalize community resources from which to seek shelter after discharge.
• B. The client will write a plan to keep herself and her children safe.
• C. The client will contact an attorney for help with pressing charges.
• D. The client will be safe and receive treatment for injuries.

Correct answer: D

Rationale: During the crisis stage of caring for a victim of domestic violence, the immediate priority is ensuring the client's safety and providing treatment for any injuries sustained. This focuses on addressing the urgent physical and emotional needs of the victim. While options like verbalizing community resources or creating safety plans are important for long-term support, they are not the primary concerns during the crisis phase. Contacting an attorney for legal assistance, though vital in the future, is not the immediate priority during the crisis stage when the client's safety and health are at the forefront.

5. What should be the initial action for a client admitted to an alcohol rehabilitation center who has a strong odor of alcohol on their breath on the fourth day after admission?

• A. Ask where the client obtained the alcohol.
• B. Locate the alcoholic substance.
• C. Convey empathy and support to the client.
• D. Document the client's drinking behavior.

Correct answer: B

Rationale: The initial action should be to locate the alcoholic substance. The nurse needs to find and remove the substance to prevent the client or others from consuming more alcohol. Asking where the client obtained the alcohol is not the priority; the focus is on ensuring the client's safety. Conveying empathy and support is essential but should not be the first action in this scenario. Documenting the client's drinking behavior can be done after ensuring immediate safety measures are in place.

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