Nursing Elites

1. During a manic episode, what is the most appropriate intervention to implement first for a client with bipolar disorder?

• A. Engage the client in a quiet activity
• B. Provide a structured environment with minimal stimulation
• C. Monitor the client continuously
• D. Adjust the lighting and noise levels

Correct answer: B

Rationale: During a manic episode, individuals with bipolar disorder may experience sensory overload and agitation. Providing a structured environment with minimal stimulation is the most appropriate initial intervention as it can help reduce overwhelming sensory input and promote a sense of calm. Engaging the client in a quiet activity (Choice A) may not be effective if the environment is still overstimulating. Continuous monitoring (Choice C) is important but may not be the first intervention needed. Adjusting lighting and noise levels (Choice D) can be helpful but may not address the core issue of sensory overload and agitation during a manic episode.

2. A client with a history of congestive heart failure is prescribed digoxin (Lanoxin). Which assessment is most important for the nurse to obtain before administering this medication?

• A. Blood pressure
• B. Heart rate
• C. Respiratory rate
• D. Oxygen saturation

Correct answer: B

Rationale: The correct answer is B: Heart rate. Before administering digoxin to a client with a history of congestive heart failure, the nurse must assess the client's heart rate. Digoxin can cause bradycardia, so monitoring the heart rate is crucial to prevent potential complications. Assessing blood pressure, respiratory rate, and oxygen saturation are important assessments but are not as directly influenced by digoxin as heart rate is in this scenario. Blood pressure can be affected by various factors, including dehydration or other medications. Respiratory rate and oxygen saturation are more related to respiratory function and gas exchange, which are not the primary concerns when administering digoxin to a client with heart failure.

3. The nurse is caring for a client with cirrhosis of the liver. Which clinical finding is most concerning?

• A. Jaundice.
• B. Ascites.
• C. Spider angiomas.
• D. Asterixis.

Correct answer: D

Rationale: The correct answer is D, Asterixis. Asterixis, also known as liver flap, is a sign of hepatic encephalopathy, a severe complication of liver disease that necessitates immediate attention. While jaundice (choice A), ascites (choice B), and spider angiomas (choice C) are common clinical findings in cirrhosis, asterixis is the most concerning due to its association with hepatic encephalopathy, which can lead to altered mental status and even coma. Jaundice, ascites, and spider angiomas are also important signs in cirrhosis, but asterixis indicates a more critical condition requiring urgent intervention.

4. The client is 4 hours post-operative from a cesarean section and complains of gas pain and bloating. What non-pharmacological intervention can the nurse provide?

• A. Encourage the client to ambulate
• B. Apply a heating pad
• C. Provide a carbonated beverage
• D. Teach relaxation techniques

Correct answer: A

Rationale: The correct answer is to encourage the client to ambulate. Early ambulation helps alleviate gas pain and bloating by promoting gastrointestinal motility and reducing the accumulation of gas in the abdomen. Applying a heating pad may provide comfort for some types of pain but is not specifically effective for gas pain. Providing a carbonated beverage can actually worsen gas pain due to the introduction of more gas into the digestive system. Teaching relaxation techniques may be beneficial for overall comfort but may not directly address the gas pain and bloating experienced post-cesarean section.

5. The nurse is planning to ambulate a client who has been on bed rest for 24 hours following a Colon Resection. To ambulate this client safely, which intervention should the nurse implement first?

• A. Place non-skid shoes on the client
• B. Show the client how to use the call light
• C. Use a gait belt to support the client
• D. Assist the client to a bedside sitting position

Correct answer: D

Rationale: To ambulate a client safely after a period of bed rest, the nurse should first assist the client to a bedside sitting position. This initial step ensures the client is stable before attempting to stand and walk, reducing the risk of falls and allowing for a gradual adjustment to activity post-bed rest. Placing non-skid shoes, showing how to use the call light, or using a gait belt are important but should come after ensuring the client is safely seated and stable.

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