Nursing Elites

1. A client with Alzheimer’s disease is becoming increasingly confused. What action should the nurse take first?

• A. Reorient the client to time and place.
• B. Monitor the client’s vital signs.
• C. Provide the client with calming activities to reduce confusion.
• D. Consult with the healthcare provider about adjusting the client’s medication.

Correct answer: B

Rationale: The correct action for the nurse to take first when a client with Alzheimer’s disease is becoming increasingly confused is to monitor the client’s vital signs (Choice B). Increased confusion in Alzheimer’s disease patients may indicate underlying issues like infection, dehydration, or medication side effects. Monitoring vital signs is crucial in identifying any potential causes of the confusion. Choices A, C, and D are not the priority in this situation. Reorienting the client to time and place (Choice A) can be helpful but is not the first priority. Providing calming activities (Choice C) and consulting with the healthcare provider about medication adjustments (Choice D) may be necessary but should come after assessing the client's vital signs to rule out immediate physical causes of confusion.

2. Why is it important for the healthcare provider to monitor blood pressure in clients receiving antipsychotic drugs?

• A. Orthostatic hypotension is a common side effect.
• B. Most antipsychotic drugs cause elevated blood pressure.
• C. This provides information on the amount of sodium allowed in the diet.
• D. It will indicate the need to institute antiparkinsonian drugs.

Correct answer: A

Rationale: Corrected Question: Monitoring blood pressure in clients receiving antipsychotic drugs is crucial because orthostatic hypotension is a common side effect. Orthostatic hypotension can lead to a sudden drop in blood pressure upon standing, increasing the risk of falls and related injuries. Therefore, regular blood pressure monitoring helps healthcare providers detect and manage this potential side effect. Incorrect Choices Rationale: - Choice B is incorrect because while antipsychotic drugs can have various side effects, causing elevated blood pressure is not a common effect associated with them. - Choice C is unrelated to blood pressure monitoring in clients receiving antipsychotic drugs. Monitoring blood pressure in this context aims to detect and manage side effects of the medication, not to assess sodium intake. - Choice D is incorrect as monitoring blood pressure in clients receiving antipsychotic drugs is primarily aimed at detecting orthostatic hypotension, not as an indicator for instituting antiparkinsonian drugs.

3. A client with hypertension has been prescribed a calcium channel blocker. What should the nurse include in the client's teaching plan?

• A. Monitor heart rate regularly
• B. Avoid potassium-rich foods
• C. Increase fluid intake to avoid dehydration
• D. Take the medication with food

Correct answer: A

Rationale: Corrected Rationale: Calcium channel blockers can cause bradycardia, so it is important for the client to monitor their heart rate regularly. This helps detect any significant changes in heart rate that may require medical attention. Choice B is incorrect because there is no need to avoid potassium-rich foods with calcium channel blockers. Choice C is incorrect as increasing fluid intake is not specifically related to calcium channel blockers. Choice D is incorrect as calcium channel blockers are usually taken with or without food, depending on the specific medication, but not specifically on an empty stomach.

4. Prior to surgery, written consent must be obtained. What is the nurse's legal responsibility with regard to obtaining written consent?

• A. Witness the consent and sign the form as a witness
• B. Inform the client of alternatives to the procedure
• C. Explain the procedure in detail to the client
• D. Determine that the surgical consent form has been signed and is included in the client's record

Correct answer: D

Rationale: The nurse's legal responsibility is to ensure that informed consent has been obtained by verifying that the client has signed the form and that it is included in the record. Witnessing the consent and signing as a witness is not the nurse's role, as this is typically done by a neutral party. Informing the client of alternatives to the procedure and explaining the procedure in detail are responsibilities of the healthcare provider performing the surgery, not the nurse.

5. The nurse is providing discharge teaching to a client with gastroesophageal reflux disease (GERD). Which instruction should the nurse include in the teaching?

• A. Increase fluid intake with meals
• B. Avoid lying down for at least 30 minutes after eating
• C. Eat small, frequent meals throughout the day
• D. Consume spicy foods in moderation

Correct answer: C

Rationale: The correct instruction for the nurse to include in the teaching for a client with GERD is to eat small, frequent meals throughout the day. This recommendation helps reduce symptoms by preventing the stomach from becoming overly full, which can increase pressure on the lower esophageal sphincter and lead to acid reflux. Choices A, B, and D are incorrect because increasing fluid intake with meals can exacerbate GERD symptoms, lying down after eating can worsen reflux, and consuming spicy foods can trigger acid reflux in individuals with GERD.

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