Nursing Elites

1. A female client with major depressive disorder tells the nurse she feels worthless and can't see how her life will ever get better. What is the best response by the nurse?

• A. I can understand how you feel. Tell me more about what's been going on.
• B. You're going through a tough time. Let's discuss what makes you feel this way.
• C. You sound very hopeless right now. Are you thinking about harming yourself?
• D. It's difficult to see the light when you're feeling this way, but I'm here to help you.

Correct answer: C

Rationale: Choice C is the best response because it directly addresses the client's expressed hopelessness and assesses the risk for self-harm. When a client with major depressive disorder expresses feeling worthless and unable to see improvement, it is essential to assess suicidal ideation to ensure their safety. Choices A, B, and D provide empathy and support, which are important but addressing suicidal ideation is the priority in this situation.

2. The nurse is caring for a client who is postoperative following a thyroidectomy. Which finding requires immediate intervention?

• A. Hoarse voice
• B. Slight difficulty swallowing
• C. Positive Chvostek's sign
• D. Pain at the incision site

Correct answer: C

Rationale: A positive Chvostek's sign indicates hypocalcemia, a common complication following thyroidectomy due to inadvertent parathyroid gland injury. Immediate intervention is needed to prevent severe hypocalcemia symptoms like tetany, seizures, and laryngospasm. Hoarse voice and slight difficulty swallowing are expected post-thyroidectomy and do not require immediate intervention. Pain at the incision site is common postoperatively and can be managed with appropriate pain relief measures.

3. A client with hypertension receives a prescription for enalapril, an angiotensin-converting enzyme inhibitor. What instruction should the nurse include in the medication teaching plan?

• A. Increase intake of potassium-rich foods
• B. Report increased bruising or bleeding
• C. Stop medication if a cough develops
• D. Limit intake of leafy green vegetables

Correct answer: B

Rationale: The correct answer is B: 'Report increased bruising or bleeding.' Enalapril, an ACE inhibitor, can lead to thrombocytopenia, a condition characterized by a low platelet count, which increases the risk of bruising and bleeding. Instructing the client to report any signs of increased bruising or bleeding is crucial for monitoring and managing this potential side effect. Choices A, C, and D are incorrect: A - Increasing potassium-rich foods is not directly related to the side effects of enalapril. C - Developing a cough is a common side effect of ACE inhibitors, but it does not warrant stopping the medication unless advised by a healthcare provider. D - Limiting intake of leafy green vegetables is not necessary with enalapril unless specifically instructed by a healthcare provider for individual reasons.

4. The nurse enters a client's room and observes the unlicensed assistive personnel (UAP) making an occupied bed. What action should the nurse take first?

• A. Place the side rails in an up position.
• B. Assist the UAP in turning the client.
• C. Provide instructions on proper bed-making techniques.
• D. Ask the client if they are comfortable.

Correct answer: A

Rationale: The correct answer is to place the side rails in an up position first. This action is essential to prevent the client from falling while the bed is being made. Assisting the UAP in turning the client (Choice B) is not the immediate priority. Providing instructions on bed-making techniques (Choice C) can wait until the safety of the client is ensured. Asking the client if they are comfortable (Choice D) is important but should come after ensuring the client's safety by raising the side rails.

5. A client who is receiving long-term steroid therapy complains of blurred vision. Which intervention should the nurse implement first?

• A. Instruct the client to use artificial tears to lubricate the eyes
• B. Administer an ophthalmic antibiotic as prescribed
• C. Arrange for the client to see an optometrist for an eye exam
• D. Notify the healthcare provider immediately

Correct answer: D

Rationale: The correct answer is to notify the healthcare provider immediately (Option D). Blurred vision in a client on long-term steroid therapy can be a sign of serious conditions like cataracts or glaucoma, which need urgent medical evaluation and management. Instructing the client to use artificial tears (Option A) may help with dry eyes but does not address the underlying cause of blurred vision. Administering an ophthalmic antibiotic (Option B) is not indicated unless there is a specific infection present. Referring the client to an optometrist for an eye exam (Option C) may delay necessary medical intervention by the healthcare provider, who should be involved promptly in this situation.

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