Nursing Elites

1. After a client with leukemia undergoes a bone marrow biopsy and is found to have thrombocytopenia, which nursing assessment is most important following the procedure?

• A. Observe the aspiration site
• B. Assess body temperature
• C. Monitor skin elasticity
• D. Measure urinary output

Correct answer: A

Rationale: The correct answer is to observe the aspiration site. Thrombocytopenia, characterized by a low platelet count, increases the risk of bleeding. Therefore, monitoring the biopsy site for bleeding or hematoma is crucial to ensure early detection and intervention. Assessing body temperature (choice B) is not directly related to the increased bleeding risk associated with thrombocytopenia. Monitoring skin elasticity (choice C) and measuring urinary output (choice D) are important assessments but are not the priority in this situation where bleeding risk needs immediate attention.

2. The nurse notes that a depressed female client has been more withdrawn and non-communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?

• A. Encourage the client's family to visit more often
• B. Schedule a daily conference with the social worker
• C. Encourage the client to participate in group activities
• D. Engage the client in a non-threatening conversation

Correct answer: D

Rationale: Engaging the client in a non-threatening conversation is crucial as it can help build trust and provide support, addressing the client's withdrawal. This intervention focuses on establishing a therapeutic relationship and giving the client an opportunity to express their feelings. Choices A, B, and C do not directly target the client's need for communication and may not address the underlying issues contributing to her withdrawal. Encouraging the client's family to visit more often (Choice A) may add pressure or discomfort to the client. Scheduling a daily conference with the social worker (Choice B) may not address the client's immediate need for communication. Encouraging the client to participate in group activities (Choice C) may be overwhelming for the client and not address her withdrawal directly.

3. An adolescent male client is admitted to the hospital. Based on Erikson’s theory of psychosocial development, which nursing intervention best assists this adolescent’s adjustment to his hospital stay?

• A. Invite him to participate in the evening group activity
• B. Schedule frequent private phone calls to his parents
• C. Provide access to a variety of video games in his room
• D. Encourage him to learn his way around the hospital

Correct answer: A

Rationale: Inviting the adolescent to participate in group activities aligns with Erikson's theory of psychosocial development, specifically the stage of developing social relationships. By engaging in group activities, the adolescent can interact with peers, fostering social skills and aiding in adjustment to the hospital environment. Choice B is incorrect as excessive reliance on phone calls to parents may hinder the adolescent's autonomy and independence, which are crucial aspects of Erikson's theory for this age group. Choice C, providing access to video games, while potentially offering entertainment, does not directly address the need for social interaction and relationship-building. Choice D, encouraging the adolescent to learn his way around the hospital, is important for familiarity but may not directly address the need for social interaction and adjustment in the hospital setting.

4. A female client on the mental health unit tells the nurse that her roommate is sitting on the bathroom floor with superficial cuts on her wrists. The nurse cleans and assesses the client’s wrists and asks what happened. She doesn’t respond. What should the nurse do next?

• A. Find supplies to put a dressing on the client’s wrists
• B. Take the client to a room for supervision by staff
• C. Call the healthcare provider to report the client’s behavior
• D. Go find a staff member to stay in the room with the client

Correct answer: B

Rationale: In this situation, the nurse's priority is to ensure the safety and supervision of the client. Moving the client to a room for direct supervision by staff is crucial to prevent further harm and provide immediate support. While cleaning and assessing the client's wrists are important, ensuring ongoing supervision is vital in this scenario. Calling the healthcare provider to report the behavior may be necessary but is not the immediate action required. Finding supplies to dress the client's wrists is important but not as urgent as ensuring constant supervision by staff.

5. A male client with hypercholesterolemia wants to change his diet to help reduce his cholesterol levels. Which breakfast items should the nurse encourage the client to eat? (Select all that apply)

• A. Sausage patties and eggs
• B. Whole wheat toast and jam
• C. Bagels and cream cheese
• D. Blackberries and oatmeal

Correct answer: B

Rationale: The correct choices are whole wheat toast and jam (B) and blackberries and oatmeal (D). Whole wheat toast and blackberries are high in fiber, which can help lower cholesterol levels. Sausage patties and eggs (A) are high in saturated fats that can raise cholesterol levels. Bagels and cream cheese (C) are not as beneficial for cholesterol control compared to high-fiber options like whole wheat toast and blackberries.

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