Nursing Elites

1. A client tells the nurse he is fearful of planned surgery because of evil thoughts about a family member. What is the best initial response by the nurse?

• A. Call a chaplain
• B. Deny the feelings
• C. Cite recovery statistics
• D. Listen to the client

Correct answer: D

Rationale: The correct answer is to listen to the client. Listening allows the nurse to establish therapeutic communication, understand the client's fears and concerns, provide emotional support, and help alleviate anxiety. Calling a chaplain (Choice A) may be appropriate if the client requests spiritual support but should not be the initial response. Denying the feelings (Choice B) is dismissive and can hinder trust and communication. Citing recovery statistics (Choice C) is irrelevant and does not address the client's immediate emotional needs.

2. A 16-year-old client is admitted to a psychiatric unit with a diagnosis of attempted suicide. The nurse is aware that the most frequent cause for suicide in adolescents is

• A. Progressive failure to adapt
• B. Feelings of anger or hostility
• C. Reunion wish or fantasy
• D. Feelings of alienation or isolation

Correct answer: D

Rationale: Feelings of alienation or isolation are common triggers for suicidal behavior in adolescents. This sense of being disconnected or isolated from others can lead to despair and hopelessness, increasing the risk of suicidal ideation. Choices A, B, and C are less commonly associated with suicide in adolescents. Progressive failure to adapt may contribute to stress, but it is not typically the primary cause of suicide. Feelings of anger or hostility, while negative emotions, do not always lead to suicidal behavior in adolescents. Reunion wish or fantasy is not a recognized primary cause of suicide in this age group.

3. A client is admitted for COPD. Which finding would require the nurse's immediate attention?

• A. Nausea and vomiting
• B. Restlessness and confusion
• C. Low-grade fever and cough
• D. Irritating cough and liquefied sputum

Correct answer: B

Rationale: Restlessness and confusion are signs of hypoxia and hypercapnia in a client with COPD, indicating that the client's condition may be deteriorating rapidly. Immediate attention is necessary to prevent further complications. Nausea and vomiting (Choice A) may be related to various factors but do not directly indicate respiratory distress. Low-grade fever and cough (Choice C) are common in COPD and may not require immediate intervention. Irritating cough and liquefied sputum (Choice D) are typical symptoms of COPD exacerbation but do not signal an immediate need for attention as restlessness and confusion.

4. A client with hypothyroidism is receiving levothyroxine (Synthroid). The nurse should monitor the client for which of the following side effects?

• A. Tachycardia
• B. Hypotension
• C. Weight gain
• D. Bradycardia

Correct answer: A

Rationale: The correct answer is A: Tachycardia. Levothyroxine, used to treat hypothyroidism, can lead to increased metabolism, causing tachycardia as a side effect. Monitoring for tachycardia is essential to ensure the client's safety. Choices B, Hypotension, and C, Weight gain, are incorrect as levothyroxine is not typically associated with causing hypotension or weight gain. Choice D, Bradycardia, is also incorrect as levothyroxine-induced bradycardia is not a common side effect.

5. A client with diabetes mellitus is receiving insulin glargine (Lantus). The nurse should monitor the client for which of the following side effects?

• A. Hypoglycemia
• B. Hyperkalemia
• C. Hypertension
• D. Hypercalcemia

Correct answer: A

Rationale: Insulin glargine is a long-acting insulin used to control blood sugar levels in diabetes. The nurse should monitor the client for hypoglycemia, which is a potential side effect of insulin therapy. Hypoglycemia occurs when blood sugar levels drop too low, leading to symptoms such as shakiness, dizziness, sweating, confusion, and in severe cases, loss of consciousness. Hyperkalemia (choice B) is an elevated potassium level, not typically associated with insulin glargine. Hypertension (choice C) is high blood pressure, which is not a common side effect of insulin glargine. Hypercalcemia (choice D) is an elevated calcium level and is not related to the use of insulin glargine.

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