Nursing Elites

1. You are taking care of 5 patients today. One of your patients wants water; another needs help walking to the bathroom; another just stated that they have chest pain; and another is crying because his daughter did not visit him today. Which patient care problem must you deal with first?

• A. The water
• B. Help to the bathroom
• C. The chest pain
• D. The crying person

Correct answer: C

Rationale: The chest pain must be addressed immediately as it could indicate a serious condition like a heart attack. Treating chest pain is a top priority in healthcare settings due to the potential life-threatening nature of the symptom. Providing immediate attention to chest pain ensures prompt assessment, diagnosis, and intervention, which are crucial for patient safety and well-being. Addressing the other needs, such as providing water, assisting with bathroom needs, or emotional support, can follow once the urgent issue of chest pain has been managed. While the other patient concerns are important, the critical nature of chest pain requires immediate action to rule out severe cardiac events and provide appropriate care.

2. Which of the following would be most important for the nurse to keep in mind regarding the use of side rails for a confused patient?

• A. A person of small stature is at increased risk for injury from entrapment.
• B. A history of a previous fall from a bed with raised side rails is significant.
• C. The desire to prevent a patient from wandering is not sufficient reason for the use of side rails.
• D. Creative use of alternative measures indicates respect for the patient's dignity.

Correct answer: A

Rationale: When considering the use of side rails for a confused patient, it is crucial for the nurse to understand that individuals of small stature are at a higher risk for injury from entrapment. Studies have shown that people of small stature are more likely to slip through or between the side rails, making them vulnerable to harm. It is essential to prioritize patient safety and avoid potential risks associated with entrapment. Conversely, a history of previous falls from a bed with raised side rails is significant as it indicates a heightened risk for future serious incidents. The desire to prevent a patient from wandering alone does not justify the use of side rails; instead, alternative measures should be creatively employed to respect the patient's dignity and avoid more serious fall-related injuries.

3. Penny Thornton has had a stroke, or CVA, and is having difficulty eating on her own. Soon, she will be getting some assistive devices for eating meals. Which healthcare worker will be providing Penny with these assistive devices?

• A. A physical therapist
• B. A speech therapist
• C. A social worker
• D. An occupational therapist

Correct answer: D

Rationale: An occupational therapist is the healthcare professional responsible for assessing the needs of individuals, like Penny, regarding assistive devices that aid them in their daily activities. In this case, assistive devices for eating, such as weighted plates and specialized utensils, are crucial for helping Penny regain independence in feeding herself. Physical therapists focus more on mobility and movement, speech therapists on communication and swallowing disorders, and social workers on providing emotional and social support. Therefore, the correct choice is the occupational therapist as they specialize in activities of daily living and promoting independence.

4. An adult patient is at the clinic for a physical examination. The patient states that they are feeling 'very anxious' about the physical examination. What steps can the nurse take to make the patient more comfortable?

• A. Appear unhurried and confident when examining the patient.
• B. Leave the room when the patient undresses unless they need assistance.
• C. Ask the patient to change into an examining gown and to leave their undergarments on.
• D. Measure vital signs at the beginning of the examination to gradually accustom the patient.

Correct answer: A

Rationale: To help alleviate the patient's anxiety, the nurse should appear unhurried and confident during the examination. This can make the patient feel more at ease and reassured. It is important for the nurse to respect the patient's privacy by leaving the room while the patient changes unless assistance is needed. The patient should be instructed to change into an examining gown while leaving their undergarments on, providing a sense of comfort and familiarity. Additionally, measuring vital signs at the beginning of the examination can help gradually acclimate the patient to the process, making it less overwhelming. Therefore, the correct answer is to appear unhurried and confident when examining the patient. Choices B, C, and D are incorrect because they do not directly address the patient's anxiety or provide comfort in the same way as the correct answer.

5. When educating a client about their new prescription for warfarin, what should the nurse advise?

• A. To have his white blood cell count tested once a month
• B. To avoid any activities that could lead to injury
• C. To avoid eating leafy green vegetables
• D. Both A and B

Correct answer: B

Rationale: The correct answer is to advise the client to avoid any activities that could lead to injury when taking warfarin. Warfarin is an anticoagulant medication that decreases blood clotting, increasing the risk of bleeding. Engaging in activities that may result in injury can lead to uncontrolled bleeding, which can be serious. While monitoring white blood cell count is not specifically related to warfarin therapy, avoiding leafy green vegetables is important due to their vitamin K content, which can interfere with warfarin's effectiveness. Therefore, the client should be educated to avoid activities that could cause injury to prevent potential bleeding complications.

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