Nursing Elites

1. A client's medication sheet contains a prescription for sertraline (Zoloft). To ensure safe administration of the medication, a nurse would administer the dose:

• A. On an empty stomach
• B. At the same time each evening
• C. Evenly spaced around the clock
• D. As needed when the client complains of depression

Correct answer: B

Rationale: The correct answer is B: 'At the same time each evening.' Sertraline should be administered at the same time each evening to maintain steady drug levels and effectiveness. Choice A is incorrect because sertraline can be taken with or without food. Choice C is incorrect as sertraline does not need to be spaced around the clock. Choice D is incorrect as sertraline is a scheduled medication and should not be taken on an as-needed basis for complaints of depression.

2. Which statement about contemporary mental health nursing practice is accurate?

• A. There is one approved theoretical framework for psychiatric nursing practice.
• B. Psychiatric nursing has yet to be recognized as a core mental health discipline.
• C. Contemporary practice of psychiatric nursing is primarily focused on inpatient care.
• D. The psychiatric nursing client may be an individual, family, group, organization, or community.

Correct answer: D

Rationale: The accurate statement about contemporary mental health nursing practice is that the psychiatric nursing client may be an individual, family, group, organization, or community. Mental health nursing extends beyond individual care to address the impact of psychiatric stressors on families, groups, and entire communities. Choices A, B, and C are incorrect: A is false as there are various theoretical frameworks used in psychiatric nursing, B is inaccurate as psychiatric nursing is a core discipline in mental health, and C is wrong as contemporary psychiatric nursing involves various settings beyond just inpatient care.

3. The nurse suspects child abuse when assessing a 3-year-old boy and noticing several small, round burns on his legs and trunk that might be the result of cigarette burns. Which parental behavior provides the greatest validation for such suspicions?

• A. The parents' explanation of how the burns occurred is different from the child's explanation of how they occurred.
• B. The parents seem to dismiss the severity of the child's burns, saying they are very small and have not posed any problem.
• C. The parents become very anxious when the nurse suggests that the child may need to be admitted for further evaluation.
• D. The parents tell the nurse that the child was burned in a house fire which is incompatible with the nurse's observation of the type of burn.

Correct answer: D

Rationale: (D) provides the most validation for suspecting child abuse. The parent's explanation (subjective data) that the child was burned in a house fire is incompatible with the objective data observed by the nurse (small, round burns on the legs and trunk). (A) relies on subjective data, and the child's explanation might not accurately reflect the situation due to various factors like age or fear. The apparent lack of concern from the parents (B) is inconclusive as the nurse's interpretation of their reaction could be subjective. While parental anxiety (C) could hint at potential child abuse, it's important to note that most parents would naturally be anxious about their child's hospitalization, making it a less definitive indicator compared to the inconsistency in the explanation provided by the parents in option (D).

4. A client with schizophrenia is being treated with clozapine (Clozaril). What laboratory test is most important for the nurse to monitor?

• A. Liver function tests
• B. Kidney function tests
• C. White blood cell count
• D. Blood glucose levels

Correct answer: C

Rationale: The correct answer is C: White blood cell count. Clozapine can lead to agranulocytosis, a severe drop in white blood cells, which can be life-threatening. Monitoring the white blood cell count is crucial to detect this condition early. Choices A, B, and D are incorrect because while liver and kidney function tests are important in monitoring other aspects of health, the most critical concern with clozapine therapy is the risk of agranulocytosis, making monitoring white blood cell count the priority.

5. Which action should the nurse implement first for a client experiencing alcohol withdrawal?

• A. Apply vest or extremity restraints.
• B. Give an alpha-adrenergic blocker.
• C. Provide a diet high in protein and calories.
• D. Prepare the environment to prevent self-injury.

Correct answer: D

Rationale: The correct action for the nurse to implement first for a client experiencing alcohol withdrawal is to prepare the environment to prevent self-injury. Clients undergoing alcohol withdrawal are at risk of seizures and other symptoms that may lead to self-harm. By ensuring a safe environment, the nurse can mitigate the risk of injury. Applying restraints (Choice A) should only be considered if less restrictive measures fail, as restraints can agitate the client further. Giving an alpha-adrenergic blocker (Choice B) may be part of the treatment plan for alcohol withdrawal but is not the first action to take. Providing a diet high in protein and calories (Choice C) is important for overall health but is not the priority when addressing immediate safety concerns.

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