Nursing Elites

1. A nurse is caring for a client in a mental health facility. The client’s daughter is crying and tells the nurse that she feels guilty for leaving her father in the hospital. Which of the following is an appropriate response?

• A. I’d like to know more about what’s bothering you.
• B. Why are you feeling this way?
• C. You did the right thing by bringing him here.
• D. I’m sure your father doesn’t blame you.

Correct answer: A

Rationale: The correct response is A: 'I’d like to know more about what’s bothering you.' Encouraging the daughter to express her feelings allows her to explore her emotions, which can be helpful in addressing her guilt and providing emotional support. Choice B is not as open-ended and may come across as confrontational. Choice C may invalidate the daughter's feelings of guilt by implying she shouldn't feel that way. Choice D assumes the father's emotions and may not address the daughter's feelings of guilt effectively.

2. A nurse is providing discharge teaching to a client who has schizophrenia and is starting therapy with clozapine. Which of the following is the highest priority to report to the provider?

• A. Constipation
• B. Blurred vision
• C. Fever
• D. Dry mouth

Correct answer: C

Rationale: The correct answer is C: Fever. Clozapine can cause agranulocytosis, a serious condition that leads to infections. Fever may indicate an underlying infection, a potentially life-threatening complication, and must be reported immediately to the provider for further evaluation and management. Choice A (Constipation) is a common side effect of clozapine but is not as urgent as fever. Blurred vision (Choice B) and dry mouth (Choice D) are side effects of clozapine but are not indicative of a life-threatening condition like agranulocytosis.

3. A client is receiving morphine. Which of the following should the nurse monitor?

• A. Liver function
• B. Respiratory rate
• C. Blood glucose levels
• D. Bowel sounds

Correct answer: B

Rationale: Corrected Rationale: When a client is receiving morphine, monitoring the respiratory rate is crucial because morphine can cause respiratory depression. Therefore, it is essential for the nurse to assess the client's breathing to detect any signs of respiratory distress. Choices A, C, and D are incorrect because morphine primarily affects the respiratory system, not the liver function, blood glucose levels, or bowel sounds.

4. A nurse is reviewing the medication class, benzodiazepines. The nurse would use caution when administering benzodiazepines to which of the clients below?

• A. A client with glaucoma
• B. A client with renal failure
• C. A client with hypertension
• D. A client with insomnia

Correct answer: A

Rationale: Benzodiazepines can increase intraocular pressure, which is why they must be used cautiously in patients with glaucoma. In clients with this condition, benzodiazepines can potentially worsen symptoms and lead to further complications involving the eyes. Therefore, administering benzodiazepines to a client with glaucoma should be done with caution. Choices B, C, and D are not directly contraindicated with benzodiazepines, making them less likely to cause harm compared to administering to a client with glaucoma.

5. A healthcare provider is assessing a client who has a long arm cast. Which of the following findings indicates a moderate complication when assessing for acute compartment syndrome?

• A. Shortness of breath
• B. Petechiae
• C. Change in mental status
• D. Edema

Correct answer: D

Rationale: Edema is a common sign of acute compartment syndrome, which is a medical emergency caused by increased pressure within a muscle compartment, requiring immediate intervention. Shortness of breath (Choice A) is more indicative of a respiratory issue rather than acute compartment syndrome. Petechiae (Choice B) are pinpoint, round spots that appear on the skin due to bleeding under the skin and are not typically associated with acute compartment syndrome. Change in mental status (Choice C) is more suggestive of neurological issues rather than acute compartment syndrome.

Similar Questions