Nursing Elites

1. A client comes to the clinic for assessment of his physical status and guidelines for starting a weight-reduction diet. The client's weight is 216 pounds and his height is 66 inches. The nurse identifies the BMI (body mass index) as:

• A. Within normal limits, so a weight-reduction diet is unnecessary.
• B. Lower than normal, so education about nutrient-dense foods is needed.
• C. Indicating obesity because the BMI is 35.
• D. Indicating overweight status because the BMI is 27.

Correct answer: C

Rationale: Obesity is defined by a BMI of 30 or more with no co-morbid conditions. Body Mass Index (BMI) is calculated by utilizing a chart or nomogram that plots height and weight. In this case, the client's BMI is calculated as 35, indicating obesity. A BMI of 27 falls within the overweight range, not obesity (which starts at 30). Choices A and B are incorrect because a BMI of 35 indicates obesity, not normal limits or being lower than normal. Therefore, the correct answer is C, indicating obesity based on the BMI calculation.

2. A patient has a history of cardiac arrhythmia. A nurse has been ordered to give 2 units of blood to this patient. The nurse should take which of the following actions?

• A. Administer pain medication to the patient.
• B. Inform the patient's family about the procedure in person.
• C. Decrease the temperature of the blood to be given.
• D. Increase the temperature of the blood to be given.

Correct answer: D

Rationale: In patients with a history of cardiac arrhythmia, warming the blood before transfusion can help prevent additional arrhythmias. Cold blood can lead to arrhythmias and should be avoided. Administering pain medication (Choice A) is not directly related to the safe administration of blood. Informing the patient's family in person (Choice B) is important but not the immediate action required for safe transfusion. Decreasing the temperature of the blood to be given (Choice C) would increase the risk of cardiac arrhythmia, contrary to the goal of ensuring patient safety.

3. One week ago, a client was involved in a motor vehicle crash (MVC) and was brought to the Emergency Department (ED). In the emergency department, the client received two stitches to the forehead and was sent home. Today, the client's spouse notes that the client 'acts like he is drunk' and cannot control his right foot and arm. The nurse will suspect?

• A. Meningitis
• B. Absence seizure
• C. Subdural hematoma
• D. Meniere's disease

Correct answer: C

Rationale: Yes! The nurse will suspect a subdural hematoma. In this case, the client's presentation of acting intoxicated and experiencing loss of motor control in the right foot and arm is indicative of an acute subdural hematoma. This condition can occur after a head injury with a slow venous bleed, where symptoms may not show until compensation mechanisms are overwhelmed. Meningitis (choice A) usually presents with fever, headache, and neck stiffness. Absence seizure (choice B) is characterized by brief periods of unconsciousness without convulsions. Meniere's disease (choice D) manifests with symptoms like vertigo, hearing loss, and tinnitus, which do not match the client's current symptoms.

4. The manic client has just interrupted the group session with the counselor for the 4th time, explaining that she already knows this information on 'dealing with others when you are down' and constantly gets up and goes to the front. What should the nurse do at this time?

• A. Engage the client to walk with you to make another pot of coffee
• B. Ask the client to reflect on their behavior to determine if it is appropriate
• C. Ask the group to tell the client how they feel when she interrupts
• D. Instruct the client to perform jumping jacks and count aloud to get rid of some energy

Correct answer: A

Rationale: In this situation, it is important to redirect the client's energy and focus. Engaging the client in a purposeful activity like making another pot of coffee can help distract them from disruptive behavior and provide an outlet for their excess energy. This choice also helps in maintaining a therapeutic environment by involving the client in a constructive task. Asking the client to reflect on their behavior (Choice B) might not be effective during a manic episode as the client may not be in a state to critically analyze their actions. Asking the group to tell the client how they feel (Choice C) can escalate the situation and may not be appropriate in this context. Instructing the client to perform jumping jacks and count aloud (Choice D) may not address the underlying issue of disruptive behavior and may not be suitable for the current situation.

5. The schizophrenic client tells you that they are "Jesus"? and "there to save the world"?. They are reading from the Bible and warning others of hell and damnation. The whole unit is getting upset and several are beginning to cry. What should the nurse do at this time?

• A. Set limits and send the client to their room.
• B. Explain to the client that not all people are Christians.
• C. Remove the Bible from the client and explain that they are not "Jesus"?.
• D. Ask the client to share with the group how he knows that he is "Jesus"?.

Correct answer: A

Rationale: In this situation, the most appropriate action for the nurse to take is to set limits with the client and redirect them to their room. The client's behavior is disruptive and causing distress among others in the unit. Sending the client to their room allows them to cool down and prevents further agitation among other patients. Removing the client from the current environment can help de-escalate the situation. Asking the client to share how they know they are "Jesus"? (Choice D) may further agitate the situation and is not the immediate priority. Explaining to the client that not all people are Christians (Choice B) may not effectively address the disruptive behavior. Removing the Bible from the client (Choice C) without addressing the underlying issue may escalate the situation further.

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