Nursing Elites

1. A nurse in an emergency department completes an assessment on an adolescent client with conduct disorder. The client threatened suicide to a teacher at school. Which of the following statements should the nurse include in the assessment?

• A. Tell me about your siblings
• B. Tell me what kind of music you like
• C. Tell me how often you drink alcohol
• D. Tell me about your school schedule

Correct answer: C

Rationale: Asking about alcohol intake is crucial in assessing the client's risk factors and behaviors, especially in the context of a suicide threat. Understanding alcohol consumption patterns can help the nurse evaluate potential substance abuse issues and their impact on the client's mental health. Choices A, B, and D are less pertinent to the immediate concern of assessing suicide risk and conduct disorder symptoms.

2. A nurse is caring for a client who is in a seclusion room following violent behavior. The client continues to display aggressive behavior. Which of the following actions should the nurse take?

• A. Confront the client about this behavior
• B. Express sympathy for the client's situation
• C. Speak assertively to the client
• D. Stand within 30 cm (1 ft) of the client when speaking with them

Correct answer: C

Rationale: In this situation, speaking assertively is the most appropriate action for the nurse to take. Confronting the client may escalate the situation further. Expressing sympathy, although important in other contexts, may not be effective in managing aggressive behavior. Standing within close proximity to an aggressive client can compromise the nurse's safety. Therefore, speaking assertively helps to set clear boundaries and manage the situation while ensuring safety in a seclusion room.

3. A client is being taught about a new prescription for furosemide. Which of the following statements by the client indicates an understanding of the teaching?

• A. This medication will decrease my potassium levels.
• B. I should eat a banana every day to increase my potassium intake.
• C. I will stop taking this medication if I experience a cough.
• D. I should avoid drinking alcohol while taking this medication.

Correct answer: D

Rationale: The correct answer is D. Clients taking furosemide should avoid alcohol because it can lead to dehydration and potential interactions with the medication. Choices A and B are incorrect because furosemide is a diuretic that can actually lower potassium levels, so the client should not expect an increase in potassium levels or solely rely on bananas for potassium intake. Choice C is incorrect because a cough is not a common side effect of furosemide and should not be a reason to stop taking the medication.

4. What is the appropriate nursing intervention for a patient experiencing a suspected stroke?

• A. Administer thrombolytics
• B. Perform a neurological assessment
• C. Perform a CT scan
• D. Administer oxygen

Correct answer: B

Rationale: Performing a neurological assessment is the appropriate nursing intervention for a patient experiencing a suspected stroke. This assessment helps determine the severity of the stroke, identify potential deficits, and guide further interventions. Administering thrombolytics (Choice A) should only be done after a CT scan to confirm the type of stroke and rule out hemorrhagic stroke. Performing a CT scan (Choice C) is important but is typically done after stabilizing the patient. Administering oxygen (Choice D) is essential to maintain adequate oxygenation, but performing a neurological assessment takes precedence in the immediate management of a suspected stroke.

5. A nurse is reviewing the laboratory report of a client who has been taking lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect?

• A. Withhold the next dose
• B. Increase the dosage
• C. Discontinue the medication
• D. Administer the medication

Correct answer: D

Rationale: The correct answer is to administer the medication (Choice D) since the lithium level of 0.8 mEq/L falls within the therapeutic range of 0.6-1.2 mEq/L. Withholding the next dose (Choice A) or increasing the dosage (Choice B) is not necessary as the current level is appropriate. Discontinuing the medication (Choice C) is not warranted based on the given lithium level. It is crucial to maintain therapeutic levels to ensure the medication's effectiveness without causing toxicity.

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