Nursing Elites

1. While conducting an intake assessment of an adult male at a community mental health clinic, the nurse notes that his affect is flat, he responds to questions with short answers, and he reports problems with sleeping. He reports that his life partner recently died from pneumonia. Which action is most important for the nurse to implement?

• A. Encourage the client to see the clinic's grief counselor.
• B. Determine if the client has a family history of suicide attempts.
• C. Inquire about whether the life partner had AIDS.
• D. Consult with the healthcare provider about the client's need for antidepressant medications.

Correct answer: A

Rationale: The client is exhibiting symptoms of normal grief, such as flat affect, withdrawal, and sleep disturbances, following the recent death of his life partner. It is crucial for the nurse to encourage the client to see the clinic's grief counselor. Grief counseling can provide the client with appropriate support and coping strategies during this grieving process, helping him navigate through his loss and emotions effectively.

2. A postoperative client has three different PRN analgesics prescribed for varying levels of pain. The nurse inadvertently administers a dose that is not within the prescribed parameters. What action should the nurse take first?

• A. Assess for side effects of the medication.
• B. Document the client’s responses.
• C. Complete a medication error report.
• D. Determine if the pain was relieved.

Correct answer: A

Rationale: In the scenario where a nurse administers a medication outside the prescribed parameters, the immediate action should be to assess the client for any potential side effects of the medication. This is crucial to ensure the client's safety and well-being. By promptly assessing for side effects, the nurse can address any adverse reactions promptly and provide necessary interventions. Once the client's safety is ensured, documenting the client's responses, completing a medication error report, and assessing pain relief can follow as part of the broader response to the medication error. Choice B is not the first priority because the immediate concern is the potential harm from the incorrect dose. Choice C is also important but comes after ensuring the client's safety. Choice D focuses on the outcome rather than the immediate need to address any side effects of the medication.

3. A client who has a body mass index (BMI) of 30 is requesting information on the initial approach to a weight loss plan. Which action should the nurse recommend first?

• A. Plan low carbohydrate and high protein meals
• B. Engage in strenuous activity for an hour daily
• C. Keep a record of food and drinks consumed daily
• D. Participate in a group exercise class 3 times a week

Correct answer: C

Rationale: Keeping a food diary is a good first step to understand eating habits before making any dietary or activity changes.

4. The healthcare provider plans to foster a therapeutic relationship with the patient utilizing therapeutic techniques of communication. It is most important that the provider:

• A. Work on establishing rapport with the patient.
• B. Use humor to lighten emotionally charged topics of discussion.
• C. Empathize with the patient when the patient shares sad feelings.
• D. Demonstrate respect when discussing emotionally charged topics.

Correct answer: D

Rationale: In fostering a therapeutic relationship, demonstrating respect is essential as it helps the patient feel valued and understood. Respectful communication contributes to building trust and a safe environment for open and honest discussions.

5. What is the most important instruction for the nurse to provide a client with a new colostomy regarding stoma care?

• A. Cleanse the stoma with hydrogen peroxide and water.
• B. Apply a moisture barrier cream to the peristomal skin.
• C. Measure the stoma using a stoma guide.
• D. Use a dry gauze pad to clean the stoma.

Correct answer: C

Rationale: Measuring the stoma using a stoma guide (C) is crucial as it ensures that the appliance fits properly, which is essential for preventing skin irritation and leakage. Proper measurement helps in selecting the right size of the appliance, promoting comfort and optimal stoma care. In contrast, cleansing with hydrogen peroxide (A), applying a moisture barrier cream (B), and using a dry gauze pad (D) are important but not as critical as ensuring the correct fit of the stoma appliance.

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