Nursing Elites

1. A male client is admitted to the mental health unit because he experiences panic attacks when driving on the freeway. To attempt to desensitize this fear, what action should the nurse encourage the client to implement?

• A. Watch training videos of people driving in various environments
• B. Begin visualizing himself driving each route to the freeway
• C. Take antianxiety medication two hours before driving on freeways
• D. Get in the car with a support person and drive on a freeway during rush hour

Correct answer: B

Rationale: Visualization techniques, such as visualizing himself driving each route to the freeway, are commonly used in desensitization therapy to help clients gradually overcome their fears. Watching videos of others driving or taking medication do not actively involve the client in facing their fear, which is essential in desensitization therapy. Getting in the car with a support person during rush hour may exacerbate the client's anxiety rather than help in desensitization.

2. When obtaining a urine specimen from a female infant, which intervention should the nurse implement?

• A. Place the wet diaper in a biohazard specimen bag
• B. Obtain the urine sample using a straight size 4 French catheter
• C. Collect the urinary stream in mid-air when the infant cries
• D. Secure the pediatric urine collector bag to the perineum

Correct answer: D

Rationale: When obtaining a urine specimen from a female infant, securing the pediatric urine collector bag to the perineum is the most appropriate intervention. This method allows for non-invasive collection of urine without causing discomfort or distress to the infant. Placing the wet diaper in a biohazard specimen bag (Choice A) is incorrect as it does not involve collecting a fresh urine sample. Using a catheter (Choice B) is invasive and not typically necessary for routine urine specimen collection from infants. Collecting the urinary stream in mid-air when the infant cries (Choice C) is not a reliable or hygienic method of obtaining a urine specimen.

3. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 liters per minute by nasal cannula. The client develops respiratory distress and the nurse increases the oxygen to 4 liters per minute. Shortly afterward, the client becomes lethargic and confused. What action should the nurse take first?

• A. Reposition the nasal cannula
• B. Lower the oxygen rate
• C. Encourage the client to cough and deep breathe
• D. Monitor the client's oxygen saturation level

Correct answer: B

Rationale: In this scenario, the client with COPD receiving increased oxygen is experiencing oxygen toxicity, leading to lethargy and confusion. Lowering the oxygen rate is the priority action to prevent further harm. Repositioning the nasal cannula, encouraging coughing and deep breathing, and monitoring oxygen saturation are all important interventions, but the immediate concern is to address the oxygen toxicity by lowering the oxygen rate.

4. The nurse is assessing on the first postoperative day following thyroid surgery. Which laboratory value is most important for the nurse to monitor?

• A. Calcium
• B. Sodium
• C. Chloride
• D. Potassium

Correct answer: A

Rationale: Corrected Rationale: Monitoring calcium levels is crucial post-thyroid surgery to detect hypocalcemia, a common complication due to injury or removal of the parathyroid glands. Monitoring sodium, chloride, or potassium levels is not as vital in the immediate post-thyroid surgery period.

5. A client with a history of congestive heart failure (CHF) is admitted with fluid volume overload. Which assessment finding should the nurse report to the healthcare provider?

• A. Weight gain of 2 pounds in 24 hours
• B. Presence of a cough
• C. Edema in the lower extremities
• D. Shortness of breath

Correct answer: D

Rationale: The correct answer is 'D - Shortness of breath.' In a client with congestive heart failure experiencing fluid volume overload, shortness of breath is a critical finding that indicates possible pulmonary congestion and worsening heart failure. This symptom requires immediate attention to prevent further complications. Choices A, B, and C are common findings in clients with CHF but are not as urgent as shortness of breath. Weight gain may indicate fluid retention, cough can be due to pulmonary congestion, and edema in lower extremities is a common manifestation of CHF, but none of these findings are as concerning as shortness of breath in this scenario.

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