Nursing Elites

1. A newly admitted patient with major depression has lost 20 pounds over the past month and has suicidal ideation. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis.

• A. Imbalanced nutrition: Less than body requirements
• B. Chronic low self-esteem
• C. Risk for suicide
• D. Hopelessness

Correct answer: B

Rationale: The priority nursing diagnosis in this scenario is 'Risk for suicide.' When a patient presents with major depression, significant weight loss, suicidal ideation, and lack of symptom improvement despite medication, the immediate concern is to address the risk of suicide. 'Risk for suicide' takes precedence as it involves a direct threat to the patient's life. 'Imbalanced nutrition: Less than body requirements' may be a concern but does not take priority over the risk of suicide. 'Chronic low self-esteem' and 'Hopelessness' are relevant issues in depression but are not as urgent as addressing the immediate risk of suicidal behavior.

2. A 70-year-old man has a blood pressure of 150/90 mm Hg in a lying position, 130/80 mm Hg in a sitting position, and 100/60 mm Hg in a standing position. How should the nurse evaluate these findings?

• A. These readings are a normal response and attributable to changes in the patient's position.
• B. The change in blood pressure readings is called orthostatic hypotension.
• C. The blood pressure reading in the lying position is within normal limits.
• D. The change in blood pressure readings is considered within normal limits for the patient's age.

Correct answer: B

Rationale: The correct answer is, 'The change in blood pressure readings is called orthostatic hypotension.' Orthostatic hypotension is defined as a drop in systolic pressure of �20 mm Hg or �10 mm Hg drop in diastolic pressure that occurs with a quick change to a standing position. This condition is common in individuals on prolonged bed rest, older adults, those with hypovolemia, or taking specific medications. The blood pressure readings provided in the question (150/90 mm Hg lying, 130/80 mm Hg sitting, and 100/60 mm Hg standing) demonstrate a significant change in blood pressure with position changes, which is indicative of orthostatic hypotension. Choices A, C, and D are incorrect because the readings do not indicate a normal response or blood pressure within normal limits for the patient's age; rather, they suggest the presence of orthostatic hypotension.

3. A home health nurse is preparing to visit her next client, whom she has never visited before. Which of the following actions indicates the nurse is upholding safety precautions?

• A. Send a text to the client to confirm the location of the house
• B. Leave her purse and valuables on the seat in the car and lock the doors
• C. Ask the client to keep an extra set of keys in case the car is locked
• D. Keep the car windows rolled up when in an unfamiliar environment

Correct answer: D

Rationale: The correct answer is to keep the car windows rolled up when in an unfamiliar environment. This action helps uphold safety precautions for the home health nurse. When visiting a new client in an unfamiliar area, it is essential to ensure personal safety. Keeping the car windows rolled up can prevent potential intruders or unwanted individuals from gaining access to the nurse while in the vehicle. This precaution is important for personal safety and security. Choice A, sending a text to the client to confirm the location of the house, is not directly related to the nurse's safety during the visit. While communication with the client is important, it does not directly address the nurse's safety. Choice B, leaving her purse and valuables on the seat in the car, poses a security risk. It is not advisable to leave valuables visible in the car, as it may attract thieves and compromise the nurse's safety. Choice C, asking the client to keep an extra set of keys, is more related to accessibility and convenience rather than the nurse's safety. While having an extra set of keys may be helpful, it does not directly address safety precautions for the nurse.

4. The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How would the nurse assess this child's respirations?

• A. Respirations should be counted for 1 full minute.
• B. Child's pulse and respirations should be simultaneously checked for 30 seconds and then multiplied by 2.
• C. Child's respirations should be checked for a minimum of 5 minutes to identify any variations in his or her respiratory pattern.
• D. Patient's respirations should be counted for 15 seconds and then multiplied by 4.

Correct answer: A

Rationale: To accurately assess a child's respiratory pattern, the nurse should count respirations for a full minute. This duration provides a comprehensive view of the child's breathing pattern, ensuring abnormalities are not missed. Counting for only 30 seconds may not capture irregularities effectively. Checking respirations for 5 minutes is excessive and unnecessary for a routine assessment. Counting for 15 seconds and multiplying by 4 is not as precise as a full-minute count. Pulse and respirations should not be checked simultaneously; instead, the nurse should count respirations unobtrusively while appearing to take the child's pulse. Therefore, the correct approach is to count the child's respirations for 1 full minute to obtain an accurate assessment.

5. A patient states, "I'm not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up."? Which nursing intervention should have the highest priority?

• A. Self-esteem-building activities
• B. Anxiety self-control measures
• C. Sleep enhancement activities
• D. Suicide precautions

Correct answer: D

Rationale: The highest priority nursing intervention in this scenario should be suicide precautions. The patient's statement indicates suicidal ideation, which poses an immediate risk to their safety. By implementing suicide precautions, the nurse can ensure constant monitoring and intervention to prevent any self-harm. While addressing self-esteem, anxiety, and sleep issues are essential, ensuring the patient's safety by prioritizing suicide precautions is crucial. Self-esteem-building activities, anxiety self-control measures, and sleep enhancement activities are important interventions but should follow the immediate concern of preventing harm from suicidal thoughts.

Similar Questions