Nursing Elites

1. A client with a history of depression and experiencing a situational crisis is being assessed by a nurse. What action should the nurse take first?

• A. Notify the client's support system.
• B. Help the client identify personal strengths.
• C. Confirm the client's perception of the event.
• D. Teach the client relaxation techniques.

Correct answer: A

Rationale: When a client with a history of depression is experiencing a situational crisis, the first action the nurse should take is to notify the client's support system. This is crucial as the client may require immediate assistance and support. While helping the client identify personal strengths and confirming the client's perception of the event are important aspects of the assessment and intervention process, notifying the support system takes priority in ensuring the client's safety and well-being. Teaching relaxation techniques may be beneficial but addressing the client's immediate crisis through support system notification is the most appropriate initial action.

2. A nurse is reviewing the medical records of a client with a history of depression who is experiencing a situational crisis. What should the nurse do first?

• A. Confirm the client's perception of the event.
• B. Notify the client's support system.
• C. Help the client identify personal strengths.
• D. Teach the client relaxation techniques.

Correct answer: A

Rationale: Confirming the client's perception of the event is crucial in understanding how they are interpreting the crisis situation. This helps the nurse gain insight into the client's perspective, emotions, and needs. By validating the client's perception, the nurse can establish trust and rapport, which are essential in providing effective support during a crisis. Notifying the client's support system (Choice B) may be important but should come after understanding the client's perspective. Helping the client identify personal strengths (Choice C) and teaching relaxation techniques (Choice D) are valuable interventions but should follow the initial step of confirming the client's perception to ensure individualized care.

3. A nurse is caring for a client who has Cushing's syndrome. Which of the following findings should the nurse expect?

• A. Hypotension.
• B. Weight loss.
• C. Hyperkalemia.
• D. Hypercalcemia.

Correct answer: C

Rationale: In clients with Cushing's syndrome, the nurse should expect hyperkalemia. Cushing's syndrome is characterized by excess cortisol levels, which can lead to potassium retention and result in hyperkalemia. Choices A, B, and D are incorrect. Hypotension is not typically associated with Cushing's syndrome; instead, hypertension is more common due to the effects of cortisol. Weight gain, rather than weight loss, is a common symptom of Cushing's syndrome. Hypercalcemia is not a typical finding in Cushing's syndrome; instead, hypocalcemia may occur due to increased urinary calcium excretion.

4. A nurse is assessing a client who is receiving a continuous heparin infusion. Which of the following findings should the nurse report to the provider?

• A. Platelet count of 200,000/mm³
• B. aPTT of 50 seconds
• C. Hemoglobin of 14 g/dL
• D. INR of 1.0

Correct answer: D

Rationale: The correct answer is D because an INR of 1.0 is below the therapeutic range for clients receiving heparin, indicating a potential need for dosage adjustment. Platelet count (choice A) within normal range, aPTT (choice B) within therapeutic range, and hemoglobin level (choice C) are not directly related to the monitoring of heparin therapy and would not require immediate reporting to the provider.

5. What is the priority intervention for a patient with a severe allergic reaction?

• A. Administer epinephrine
• B. Administer corticosteroids
• C. Administer oxygen
• D. Administer antihistamines

Correct answer: A

Rationale: The correct answer is to administer epinephrine. Epinephrine is the first-line treatment for severe allergic reactions because it rapidly reverses the symptoms of anaphylaxis by constricting blood vessels, increasing heart rate, and relaxing airway muscles. Corticosteroids, although helpful to reduce inflammation, are not the priority in the acute management of severe allergic reactions. Oxygen may be needed to support breathing, but it is not the initial priority. Antihistamines are not as effective as epinephrine in treating severe allergic reactions and should not be the first intervention.

Similar Questions