Nursing Elites

1. A client with schizophrenia is experiencing auditory hallucinations. Which of the following actions should the nurse take?

• A. Encourage the client to lie down in a quiet room.
• B. Ask the client directly what they are hearing.
• C. Tell the client that the voices are not real.
• D. Provide headphones for the client to listen to music.

Correct answer: B

Rationale: The correct action for the nurse to take when caring for a client with schizophrenia experiencing auditory hallucinations is to ask the client directly what they are hearing. This approach helps the nurse gain insight into the client's experience, establish effective communication, and provide appropriate support. Encouraging the client to lie down in a quiet room (Choice A) may not address the hallucinations directly. Telling the client that the voices are not real (Choice C) can be invalidating and may lead to further distress. Providing headphones for music (Choice D) may not be effective in addressing the client's hallucinations.

2. What is the priority intervention when managing a client with delirium?

• A. Administer antipsychotic medication to calm the client
• B. Identify any reversible causes of delirium
• C. Provide a low-stimulation environment
• D. Administer sedative medication to control agitation

Correct answer: B

Rationale: The correct answer is to identify any reversible causes of delirium. Delirium is often caused by underlying issues such as infections, medication side effects, or metabolic imbalances. Addressing these root causes can help resolve delirium more effectively. Administering antipsychotic or sedative medications should not be the initial approach as they can worsen delirium in some cases. Providing a low-stimulation environment is beneficial but not the priority when reversible causes need to be addressed first.

3. A client with type 2 diabetes mellitus is being taught about insulin administration by a nurse. Which of the following instructions should the nurse include?

• A. Inject insulin into the muscle
• B. Rotate injection sites with each dose
• C. Store insulin at room temperature
• D. Massage the injection site after administration

Correct answer: B

Rationale: The correct instruction that the nurse should include is to rotate injection sites with each dose. This practice is essential to prevent tissue damage and ensure proper insulin absorption. Option A is incorrect because insulin should not be injected into the muscle, but rather into the subcutaneous tissue. Option C is incorrect as insulin should be stored in the refrigerator to maintain its effectiveness. Option D is incorrect as massaging the injection site after administration can lead to faster absorption and potentially hypoglycemia.

4. A client is to start taking furosemide and is being taught about dietary modifications by a nurse. Which of the following foods should the nurse recommend to the client?

• A. Cabbage
• B. Bananas
• C. Carrots
• D. Potatoes

Correct answer: B

Rationale: The correct answer is B: Bananas. Bananas are high in potassium, which helps counter the potassium-depleting effects of furosemide. Furosemide is a loop diuretic that can lead to potassium loss, so including potassium-rich foods like bananas in the diet can help maintain a healthy potassium level. Choices A, C, and D do not specifically address the potassium needs associated with furosemide therapy and are not the most appropriate recommendations in this context.

5. A nurse is caring for a client who has diabetes mellitus and is receiving insulin. Which of the following findings should the nurse report to the provider?

• A. A fasting blood glucose of 90 mg/dL
• B. A blood glucose level of 200 mg/dL
• C. A hemoglobin A1c of 6%
• D. A fasting blood glucose of 100 mg/dL

Correct answer: B

Rationale: The correct answer is B. A blood glucose level of 200 mg/dL indicates hyperglycemia, which may necessitate insulin adjustment to better control the client's blood sugar levels. A fasting blood glucose of 90 mg/dL (choice A) is within the normal range, a hemoglobin A1c of 6% (choice C) is indicative of good long-term blood sugar control, and a fasting blood glucose of 100 mg/dL (choice D) is also within the normal range. Therefore, these findings do not require immediate reporting to the provider.

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