Nursing Elites

1. A nurse is caring for a client who is experiencing a situational crisis following the loss of a job. The client states, 'I don't think I can go through this again.' Which of the following actions is the nurse's priority?

• A. Refer the client to a mental health counselor
• B. Encourage the client to express their feelings
• C. Determine if the client is experiencing psychotic thinking
• D. Ask the client about their social support system

Correct answer: C

Rationale: In this situation, the nurse's priority is to determine if the client is experiencing psychotic thinking as it addresses the immediate safety concern. Psychotic thinking may pose a risk to the client's safety or the safety of others. Referring the client to a mental health counselor (choice A) may be appropriate but not the priority when safety is a concern. Encouraging the client to express their feelings (choice B) and asking about their social support system (choice D) are essential aspects of care but are secondary to addressing immediate safety issues.

2. What is the appropriate intervention for fluid overload?

• A. Restrict fluid intake
• B. Administer diuretics
• C. Monitor vital signs
• D. All of the above

Correct answer: D

Rationale: The appropriate intervention for fluid overload involves a combination of measures, including restricting fluid intake to prevent further fluid accumulation, administering diuretics to help the body eliminate excess fluids, and closely monitoring vital signs to assess the patient's response to treatment. Therefore, all of the above options are correct. Restricting fluid intake alone may not be sufficient to address existing fluid overload without additional measures like diuretic therapy. Monitoring vital signs is essential to evaluate the effectiveness of the interventions and the patient's overall condition.

3. A nurse is teaching a client who has multiple sclerosis (MS) about strategies to reduce fatigue. Which of the following instructions should the nurse include?

• A. Exercise to the point of exhaustion
• B. Rest as needed throughout the day
• C. Avoid physical activity
• D. Exercise only once per week

Correct answer: B

Rationale: The correct instruction the nurse should include is to 'Rest as needed throughout the day.' Fatigue is a common symptom of multiple sclerosis (MS), and adequate rest is essential to manage it effectively. Resting as needed helps conserve energy and prevent fatigue from worsening. Choices A, C, and D are incorrect. 'Exercise to the point of exhaustion' is not recommended as it can lead to increased fatigue. 'Avoiding physical activity' entirely is not advisable as appropriate exercise can help maintain strength and energy levels. 'Exercising only once per week' may not be sufficient to combat fatigue and maintain overall well-being in clients with MS.

4. A nurse is assessing a client who has a brainstem injury. The nurse should expect the client to exhibit which of the following findings?

• A. Decerebrate posturing.
• B. Hypervigilance.
• C. Absence of deep tendon reflexes.
• D. Glasgow Coma Scale score of 15.

Correct answer: A

Rationale: The correct answer is A: Decerebrate posturing. Decerebrate posturing is an abnormal body posture characterized by rigid extension of the arms and legs, which indicates severe brainstem injury affecting the midbrain and pons. This posture suggests dysfunction or damage to neural pathways controlling muscle tone. Choice B, hypervigilance, is not typically associated with brainstem injury but rather with increased alertness and arousal. Choice C, absence of deep tendon reflexes, is not a specific finding related to brainstem injury. Choice D, a Glasgow Coma Scale score of 15, indicates a fully awake and alert state, which is not expected in a client with a brainstem injury.

5. A nurse is preparing to administer insulin to a client who has type 1 diabetes mellitus. After drawing up the medication, the nurse accidentally brushes the needle on the counter's surface. Which of the following actions should the nurse take?

• A. Prepare a new dose of insulin injection
• B. Administer the insulin as it is
• C. Wipe the needle with an alcohol swab
• D. Ask the provider for guidance

Correct answer: A

Rationale: The correct action for the nurse to take is to prepare a new dose of insulin injection. Accidentally brushing the needle on a contaminated surface can lead to infection risk. Administering the insulin as it is or just wiping the needle with an alcohol swab would not be sufficient to eliminate the risk of infection. Asking the provider for guidance is not necessary in this situation as the nurse can independently take the appropriate action to ensure patient safety.

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