Nursing Elites

1. A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is important for the nurse to provide?

• A. Decrease intake of fluids after the evening meal.
• B. Drink a glass of cranberry juice every day.
• C. Drink a glass of warm decaffeinated beverage at bedtime.
• D. Consult the healthcare provider about a sleeping pill.

Correct answer: A

Rationale: Nocturia is characterized by urination during the night, disrupting sleep patterns. Instructing the client to decrease intake of fluids after the evening meal (Option A) can help reduce the production of urine, thereby decreasing the need to void at night. Cranberry juice (Option B) is beneficial for preventing bladder infections but does not address the issue of nocturia. While warm decaffeinated beverages (Option C) may promote sleep, consuming fluids close to bedtime can exacerbate nocturia. Consulting the healthcare provider about a sleeping pill (Option D) is not the first-line intervention and may lead to urinary incontinence if the client is sedated and unable to awaken to void, worsening the nocturia issue.

2. The client is 5 feet from the bathroom door when he states, 'I feel faint.' Before the nurse can get the client to a chair, the client starts to fall. What is the priority action for the nurse to take?

• A. Check the client's carotid pulse
• B. Encourage the client to get to the toilet
• C. In a loud voice, call for help
• D. Gently lower the client to the floor

Correct answer: D

Rationale: The priority action for the nurse is to gently lower the client to the floor (Option D). This action is crucial to prevent injury to both the client and the nurse. Lowering the client to the floor should be done when the client is unable to support his own weight, ensuring a safe position to prevent falls. Checking the client's carotid pulse (Option A) is important, but it should be performed after ensuring the client's safety. Encouraging the client to get to the toilet (Option B) is impractical as the client is already falling. Calling for help in a loud voice (Option C) may cause chaos and alarm other clients, making it a less suitable immediate action in this scenario.

3. The parents of a child often try to persuade their preschooler to touch their pet dog to reduce the child's fear of dogs. Instead, the child's fears and anxiety increase. Which advice would the nurse suggest to help overcome their child's fear?

• A. Ask the child to touch the dog's back gently.
• B. Keep the child away from dogs for a few years.
• C. Let the child watch other children playing with dogs.
• D. Bring in a pet cat to familiarize the child with animals.

Correct answer: C

Rationale: To help the child overcome their fear of dogs, the nurse should recommend letting the child watch other children playing with dogs. This approach allows the child to observe interactions with dogs in a safe environment, gradually building comfort and familiarity. Encouraging the child to touch the dog's back gently may increase fear and anxiety, as it could be overwhelming for the child. Keeping the child away from dogs for a few years does not address the fear directly and may not help the child overcome it. Bringing in a pet cat, while introducing the child to animals, does not specifically target the fear of dogs and may not effectively reduce the fear and anxiety associated with dogs.

4. While reviewing the side effects of a newly prescribed medication, a 72-year-old client notes that one of the side effects is a reduction in sexual drive. Which is the best response by the nurse?

• A. How will this affect your present sexual activity?
• B. How active is your current sex life?
• C. How has your sex life changed as you have become older?
• D. Tell me about your sexual needs as an older adult.

Correct answer: A

Rationale: The best response in this scenario is option A, 'How will this affect your present sexual activity?' This response directly addresses the client's concern and allows them to express their thoughts and feelings. Option B does not directly address the client's worry about the medication's side effect. Options C and D deviate from the client's immediate concern and are not as relevant in this situation.

5. Which of the following is a symptom associated with sensory overload?

• A. Disorientation
• B. Drowsiness
• C. Emotional lability
• D. Depression

Correct answer: A

Rationale: Disorientation is a common symptom associated with sensory overload. When an individual experiences sensory overload, their brain may become overwhelmed with excessive information, leading to disorientation. This can manifest as an inability to concentrate, racing thoughts, and restless behavior. Sensory overload occurs when a person is unable to either control the amount of environmental stimuli they are exposed to or process the stimuli effectively. Drowsiness, emotional lability, and depression are not typical symptoms of sensory overload. Drowsiness may indicate fatigue or boredom, emotional lability refers to rapid and exaggerated changes in mood, and depression is a mood disorder characterized by persistent feelings of sadness and hopelessness.

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