Nursing Elites

1. A 14-year-old boy has been admitted to a mental health unit for observation and treatment. The boy becomes agitated and starts yelling at nursing staff members. What should the nurse's first response be?

• A. Create an atmosphere of seclusion for the boy according to procedures.
• B. Remove other patients from the area for added safety.
• C. Ask the patient, "What is making you mad?"?
• D. Ask the patient, "Why are you behaving this way? Have you thought about what may help you calm down?"?

Correct answer: A

Rationale: In a situation where a patient is agitated and yelling, the first response should be to create an atmosphere of seclusion for the safety of the patient and others. Seclusion is a standard procedure to help manage aggressive behaviors and prevent harm. Options B, C, and D are not appropriate in this scenario. Removing other patients may not address the immediate safety concern, asking the patient what is making them mad can escalate the situation, and questioning why the patient is behaving that way may not help in managing the current agitation. Therefore, seclusion is the recommended course of action in this scenario to ensure the safety and well-being of all involved.

2. What is the best position for a client immediately following a bilateral salpingooophorectomy?

• A. Fowler's
• B. Modified Sims
• C. Side lying
• D. Flat supine

Correct answer: C

Rationale: The best position for a client immediately following a bilateral salpingooophorectomy is side lying. This position promotes comfort with the knees flexed and ensures proper airway management. Fowler's position (Choice A) would not be ideal as it involves sitting at a 90-degree angle, potentially causing discomfort after this procedure. Modified Sims position (Choice B) is typically used for rectal examinations, not for post-surgical management. Flat supine (Choice D) may not be the best choice immediately after surgery as it does not provide the same level of comfort and airway protection as side lying with knees flexed.

3. Because of the possible nervous system side-effects that occur with isoniazid (Nydrazid) therapy, which supplementary nutritional agent would the nurse teach the client to take as a prophylaxis?

• A. Alpha tocopherol (vitamin E)
• B. Ascorbic acid (vitamin C)
• C. Calcitriol (vitamin D)
• D. Pyridoxine (vitamin B6)

Correct answer: D

Rationale: Pyridoxine is the correct choice in this scenario because it is used as a prophylaxis to prevent neuritis, a possible nervous system side-effect of isoniazid therapy. Neuritis is a condition that involves inflammation of the nerves and can be a side effect of isoniazid. Pyridoxine, also known as vitamin B6, helps prevent this side effect. Vitamin E (Alpha tocopherol), vitamin C (Ascorbic acid), and vitamin D (Calcitriol) do not specifically address the nervous system side-effects associated with isoniazid therapy, making them incorrect choices.

4. Which type of exercises might be prescribed to strengthen the pelvic floor muscles of a client with urinary incontinence?

• A. Kegel
• B. resistance
• C. passive
• D. stretching

Correct answer: A

Rationale: The correct answer is Kegel. Kegel exercises are specifically designed to strengthen the pelvic floor muscles, making them an effective treatment for urinary incontinence. These exercises involve contracting and relaxing the pelvic floor muscles, which helps to improve muscle tone and control. Choice B, resistance exercises, may not directly target the pelvic floor muscles as effectively as Kegel exercises. Passive exercises (Choice C) do not actively engage the muscles and are unlikely to strengthen the pelvic floor. Stretching exercises (Choice D) focus on increasing flexibility rather than muscle strength, so they are not the most appropriate for strengthening the pelvic floor muscles in the context of urinary incontinence.

5. A client is being taught about self-administration of Haldol 15 mg po hs. For which side effect/s should the client seek medical attention?

• A. Shortness of breath and fatigue
• B. Restlessness and muscle spasms
• C. Dry mouth
• D. Diarrhea

Correct answer: B

Rationale: The correct answer is restlessness and muscle spasms. Haldol, an antipsychotic medication, can cause extrapyramidal side effects such as muscle spasms and restlessness. These side effects can be serious and should prompt the client to seek medical attention. Shortness of breath, fatigue, dry mouth, and diarrhea are not commonly associated with Haldol use, making choices A, C, and D incorrect.

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