Nursing Elites

1. The nurse enters a client’s room and the client is demanding release from the hospital. The nurse reviews the client’s record and notes that the client was admitted 2 days ago for treatment of an anxiety disorder, and the admission was voluntary. Which intervention should the nurse initiate first?

• A. Telephone the client’s family and have them persuade the client to stay
• B. Have the client read and sign all the appropriate self-discharge papers
• C. Explain to the client that he cannot leave because he asked for treatment
• D. Notify the client’s healthcare provider of the client’s stated intent to leave the hospital

Correct answer: D

Rationale: The correct intervention for the nurse to initiate first is to notify the client’s healthcare provider of the client’s intention to leave the hospital. This is important to ensure that the client’s care and safety are appropriately managed. Option A is incorrect as involving the family without proper assessment or intervention could violate the client's autonomy. Option B is incorrect because it does not involve the healthcare provider in the decision-making process. Option C is incorrect as it does not address the client's rights to make decisions about their own care.

2. Which of the following is a primary factor that affects blood pressure?

• A. Obesity
• B. Age
• C. Stress
• D. Gender

Correct answer: A

Rationale: Obesity is a primary factor that affects blood pressure. Excess body weight, especially when concentrated around the abdomen, can increase the risk of hypertension (high blood pressure) as it puts extra strain on the heart to pump blood around the body. This can lead to various cardiovascular complications and other health issues. Managing weight through a healthy diet and regular physical activity can help control blood pressure levels. Age, stress, and gender can also influence blood pressure but are not primary factors like obesity.

3. During a synchronized cardioversion on a client in atrial fibrillation, when the machine is activated and there is a pause, what action should the nurse take?

• A. Wait until the machine discharges
• B. Shout “all clear” and don’t touch the bed
• C. Make sure the client is all right
• D. Increase the joules and re-discharge

Correct answer: B

Rationale: The correct action for the nurse to take when there is a pause after activating the machine for synchronized cardioversion on a client in atrial fibrillation is to shout “all clear” and not touch the bed. This step is crucial to ensure the safety of everyone present by warning them that the machine will discharge, preventing anyone from being inadvertently shocked. Waiting for the machine to discharge (choice A) is not recommended as it can lead to accidental injury. While ensuring the client is all right (choice C) is important, the immediate focus should be on safety during the procedure. Increasing the joules and re-discharging (choice D) without assessing the situation can pose risks to the client and the healthcare team.

4. The hypertonicity of the muscles in an infant with cerebral palsy causes scissoring of the legs. The nurse teaches the mother that the preferred way to carry the infant is in a sitting position:

• A. Astride one of her hips
• B. Strapped in an infant seat
• C. Wrapped tightly in a blanket
• D. Under the arm using a football hold

Correct answer: A

Rationale: The correct way to carry an infant with cerebral palsy experiencing muscle hypertonicity and scissoring of the legs is astride one of the mother's hips. This position helps keep the infant's legs apart, reducing muscle tightness. Strapping the infant in an infant seat, wrapping tightly in a blanket, or using the football hold under the arm does not address the specific needs related to muscle hypertonicity and scissoring of the legs in cerebral palsy.

5. The type of lipoprotein that carries cholesterol from tissues to the liver for excretion is:

• A. Very low-density lipoprotein
• B. Intermediate-density lipoprotein
• C. Low-density lipoprotein
• D. High-density lipoprotein

Correct answer: D

Rationale: The correct answer is D, High-density lipoprotein (HDL). HDL is known as the 'good' cholesterol and plays a crucial role in transporting cholesterol from tissues back to the liver for excretion. This process helps in reducing the buildup of cholesterol in the bloodstream, thus lowering the risk of heart diseases. Very low-density lipoprotein (Option A), Intermediate-density lipoprotein (Option B), and Low-density lipoprotein (Option C) are not responsible for carrying cholesterol back to the liver for excretion like HDL does. Instead, they are associated with different functions related to cholesterol transportation within the body.

Similar Questions