Nursing Elites

1. A client arrives at an occupational health clinic after being struck by lightning while working in a truck bed. The client is alert but reports feeling faint. Which assessment will the nurse perform first?

• A. Pulse characteristics
• B. Open airway
• C. Entrance and exit wounds
• D. Cervical spine injury

Correct answer: A

Rationale: Assessing pulse characteristics is the priority in this situation due to the potential impact of lightning as a form of electrical current, which can cause irregular heart rhythms. It is crucial to evaluate the pulse rate and regularity to assess for adequate circulation and potential cardiac issues. Since the client is alert and talking, the airway is likely patent, making assessing the airway less urgent. Entrance and exit wounds and cervical spine injury assessments should follow the evaluation of pulse characteristics to ensure proper circulation and prioritize life-threatening issues first. Checking the pulse first will guide further interventions and help in determining the client's hemodynamic status.

2. An older woman has lived alone since the death of her husband 10 years ago, and she has a long list of vague complaints. Which assessment is the priority for the home health nurse to perform?

• A. Assess for feelings of loneliness and isolation.
• B. Determine if the client has unresolved grief.
• C. Determine if there are safety issues.
• D. Ask about the availability of support systems.

Correct answer: C

Rationale: The priority assessment for the home health nurse in this scenario is to determine if there are safety issues. The client is an older woman living alone with a long list of vague complaints, indicating several risk factors. Ensuring her safety should be the primary concern. While assessing for feelings of loneliness, isolation, or grief is important, ensuring the client's safety takes precedence due to her vulnerable situation. Although assessing the availability of support systems is essential in a home health assessment, safety issues must be addressed first given the client's profile.

3. A 5-year-old child has been recently admitted to the hospital. According to Erik Erikson's psychosocial development stages, the child is in which stage?

• A. Trust vs. mistrust
• B. Initiative vs. guilt
• C. Autonomy vs. shame and doubt
• D. Intimacy vs. isolation

Correct answer: B

Rationale: The correct answer is 'Initiative vs. guilt.' According to Erik Erikson's psychosocial development stages, children aged 3-6 years old are in the stage of initiative versus guilt. During this stage, children begin to assert their power and control over the environment. They develop a sense of purpose and direction, but may also experience feelings of guilt if they believe their actions have caused harm or conflict. Choices A, C, and D are incorrect. 'Trust vs. mistrust' is the first stage for infants, 'Autonomy vs. shame and doubt' is the second stage for toddlers, and 'Intimacy vs. isolation' is a stage that occurs later in adulthood.

4. What is the nurse's priority action when a client receiving a unit of packed red blood cells experiences tingling in the fingers and headache?

• A. Call the health care provider (HCP).
• B. Stop the transfusion.
• C. Slow the infusion rate.
• D. Assess the intravenous (IV) site for infiltration.

Correct answer: B

Rationale: When a client receiving a packed red blood cell transfusion experiences tingling in the fingers and headache, these symptoms may indicate an adverse reaction to the transfusion. The nurse's priority action is to immediately stop the transfusion and initiate a normal saline infusion at a keep vein open (KVO) rate. This helps maintain the client's vein patency while addressing the adverse reactions. After stopping the transfusion and initiating the saline infusion, the nurse should assess the client, including vital signs evaluation. Subsequently, the healthcare provider should be notified. Calling the healthcare provider is important, but it should be done after the immediate action of stopping the transfusion. Slowing the infusion rate is not appropriate during a suspected transfusion reaction as it can exacerbate the adverse effects. Assessing the IV site for infiltration is a routine nursing intervention and is not the priority when managing a potential adverse reaction to a blood transfusion.

5. After being medicated for anxiety, the client says to the nurse, 'I guess you are too busy to stay with me.' Which response by the nurse is correct?

• A. I'm so sorry, but I need to see other clients.'
• B. 'I have to go now, but I will come back in 10 minutes.'
• C. You'll be able to rest after the medicine starts working.'
• D. You'll feel better after I've made you more comfortable.'

Correct answer: B

Rationale: The nurse should respond with empathy and reassurance to address the client's emotional needs. The correct response, 'I have to go now, but I will come back in 10 minutes,' acknowledges the client's feelings while providing a timeframe for the nurse's return, showing care and concern. Choice A, 'I'm so sorry, but I need to see other clients,' prioritizes other tasks over the client's emotional needs, which can increase anxiety. Choice C, 'You'll be able to rest after the medicine starts working,' offers false reassurance and does not address the client's immediate emotional distress. Choice D, 'You'll feel better after I've made you more comfortable,' does not acknowledge the client's concerns and fails to establish a supportive connection with the client.

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