Nursing Elites

1. A client reports severe pain unrelieved by pain medication in a limb with traction. What is the nurse's priority?

• A. Increase the dosage of pain medication.
• B. Assess for compartment syndrome.
• C. Wait for the healthcare provider to address the issue.
• D. Reposition the client to alleviate the pain.

Correct answer: B

Rationale: The correct answer is B: Assess for compartment syndrome. Severe unrelieved pain in a limb with traction can be a sign of compartment syndrome, a surgical emergency. Prompt assessment is crucial to prevent potential complications. Increasing pain medication dosage without addressing the underlying cause may delay necessary interventions. Waiting for the healthcare provider may lead to a critical delay in treatment. Repositioning the client may not alleviate the pain if it is due to compartment syndrome, and it is crucial to assess for this condition first.

2. A nurse is observing a patient's use of a walker. Which observation indicates a need for further teaching?

• A. The patient advances the walker too far ahead.
• B. The patient uses the walker to assist in standing.
• C. The patient maintains their balance while using the walker.
• D. The patient walks with their back hunched over.

Correct answer: A

Rationale: The correct answer is A because advancing the walker too far ahead increases the risk of falls, indicating a need for further teaching. Choice B is correct as using the walker to assist in standing is a proper use. Choice C is correct as maintaining balance while using the walker shows proper technique. Choice D is incorrect as walking with the back hunched over is a posture issue, not directly related to walker use.

3. A client with a new diagnosis of type 1 diabetes mellitus is being taught about self-administration of insulin by a nurse. Which of the following instructions should the nurse include?

• A. Store the current bottle of insulin at room temperature
• B. Massage the injection site after removing the needle
• C. Pull back on the plunger after injecting the insulin
• D. Use each syringe up to six times

Correct answer: A

Rationale: The correct answer is to store the current bottle of insulin at room temperature. Insulin should be stored this way to maintain its potency and effectiveness. Choice B is incorrect because massaging the injection site after removing the needle is not recommended practice and can cause bruising. Choice C is incorrect as pulling back on the plunger after injecting insulin can lead to injecting air bubbles into the tissue. Choice D is incorrect as syringes should not be reused multiple times due to the risk of contamination and inaccurate dosing.

4. Which of the following is a recommended approach for handling aggressive behavior in a mental health setting?

• A. Encourage the client to express their feelings through physical activity
• B. Avoid making eye contact to prevent escalation
• C. Use pharmacological interventions immediately
• D. Maintain eye contact, offer clear choices, and set boundaries

Correct answer: D

Rationale: The recommended approach for handling aggressive behavior in a mental health setting is to maintain eye contact, offer clear choices, and set boundaries. This approach can help de-escalate the situation by establishing communication and structure. Choice A is incorrect as encouraging physical activity may not be suitable during an aggressive episode. Choice B is incorrect because avoiding eye contact can hinder communication and resolution. Choice C is also incorrect as pharmacological interventions should not be the immediate go-to method for managing aggression unless absolutely necessary.

5. Which question is essential during screening for alcohol use disorder?

• A. What is your current employment status?
• B. Have you experienced any blackouts or loss of consciousness?
• C. Have you been sleeping well over the past month?
• D. Do you have a family history of substance use?

Correct answer: B

Rationale: The essential question during screening for alcohol use disorder is asking about blackouts or loss of consciousness, which can be indicative of excessive drinking and related to alcohol use disorder. Choices A, C, and D are not as directly related to screening for alcohol use disorder. Employment status (Choice A) is not a primary question in alcohol use disorder screening. Sleep quality (Choice C) and family history of substance use (Choice D) may be relevant but are not as crucial as inquiring about blackouts or loss of consciousness.

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