Nursing Elites

1. A male client with schizophrenia is socially reclusive and pacing in the hallway. What is the most important intervention for the nurse to implement?

• A. Take the client's temperature and blood pressure.
• B. Encourage the client to rest.
• C. Plan an activity that includes physical exercise.
• D. Carefully observe the client throughout the shift.

Correct answer: D

Rationale: The correct answer is to carefully observe the client throughout the shift. In this situation, the client's behavior suggests agitation and restlessness, which could potentially escalate. Observation is crucial to monitor any changes in behavior, assess for signs of distress, and ensure the client's safety. Taking the client's temperature and blood pressure (Choice A) may not address the immediate need for managing the client's behavior. Encouraging the client to rest (Choice B) might not be effective if the client is highly agitated. Planning an activity that includes physical exercise (Choice C) could exacerbate the situation rather than address the current behavior. Therefore, the priority is to observe the client closely to provide appropriate support and intervention as needed.

2. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up?

• A. Increased appetite
• B. Describes life without purpose
• C. Exhibits mood swings
• D. Complains of insomnia

Correct answer: B

Rationale: An adolescent expressing 'life without purpose' after taking duloxetine (Cymbalta) may be indicating suicidal ideation, which requires immediate attention. The initial period of antidepressant treatment can increase the risk of suicidal thoughts, especially in younger populations. Increased appetite (Choice A) is a common side effect of duloxetine and may not require immediate follow-up. Mood swings (Choice C) and insomnia (Choice D) are also possible side effects of the medication but are not as urgent as addressing suicidal ideation.

3. An S3 heart sound is auscultated in a client in her third trimester of pregnancy. What intervention should the nurse take?

• A. Perform a 12-lead electrocardiogram
• B. Document in the client's record
• C. Notify the healthcare provider immediately
• D. Assess for signs of heart failure

Correct answer: B

Rationale: An S3 heart sound is often a normal finding in pregnant women due to increased blood volume and cardiac output. The nurse should document the finding as part of the routine assessment unless accompanied by other abnormal symptoms. Performing a 12-lead electrocardiogram (Choice A) is unnecessary for a normal S3 heart sound in pregnancy. Notifying the healthcare provider immediately (Choice C) is premature and may lead to unnecessary interventions. Assessing for signs of heart failure (Choice D) is not indicated as an isolated S3 heart sound is typically benign in pregnancy.

4. When monitoring tissue perfusion following an above the knee amputation (AKA), which action should the nurse include in the plan of care?

• A. Evaluate the closest proximal pulse.
• B. Observe the color and amount of wound drainage.
• C. Observe for swelling around the stump.
• D. Assess the skin elasticity of the stump.

Correct answer: A

Rationale: Evaluating the closest proximal pulse is essential when monitoring tissue perfusion post-amputation. This pulse provides crucial information about the circulation and perfusion to the limb. Observing the color and amount of wound drainage (Choice B) is more related to wound healing assessment rather than tissue perfusion. Observing for swelling around the stump (Choice C) may indicate inflammation or infection but is not the most direct assessment of tissue perfusion. Assessing skin elasticity of the stump (Choice D) is important for skin integrity but does not directly reflect tissue perfusion.

5. A female client with acute respiratory distress syndrome (ARDS) is sedated and on a ventilator with 50% FIO2. What assessment finding warrants immediate intervention?

• A. Assess the client’s lung sounds bilaterally.
• B. Diminished left lower lobe sounds.
• C. Monitor ventilator settings for changes in oxygen levels.
• D. Increased sputum production and shortness of breath.

Correct answer: B

Rationale: Diminished breath sounds in a sedated client with ARDS and on a ventilator indicate collapsed alveoli, which requires immediate intervention, such as chest tube insertion, to prevent further lung damage. Assessing bilateral lung sounds (Choice A) is important but not as urgent as identifying diminished sounds in a specific location. Monitoring ventilator settings (Choice C) is essential but does not directly address the immediate need for intervention due to diminished breath sounds. Increased sputum production and shortness of breath (Choice D) may indicate other issues but are not specific to the urgency of addressing diminished breath sounds in ARDS.

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