Nursing Elites

1. A healthcare provider is monitoring a client for adverse effects following the administration of an opioid. Which of the following effects should the provider identify as an adverse effect of opioids?

• A. Urinary incontinence
• B. Diarrhea
• C. Bradypnea
• D. Orthostatic hypotension

Correct answer: D

Rationale: The correct answer is D: Orthostatic hypotension. Opioids can cause orthostatic hypotension, leading to a sudden drop in blood pressure when changing positions. This effect is due to the vasodilatory properties of opioids, which can result in decreased blood flow to the brain upon standing up. Choices A, B, and C are incorrect. Urinary incontinence and diarrhea are not typical adverse effects of opioids. Bradypnea, or slow breathing, is a potential side effect of opioid overdose or respiratory depression, but it is not a common adverse effect following normal opioid administration.

2. A nurse is teaching an older adult client who has type 2 diabetes mellitus about how to care for corns and calluses on her toes. Which of the following statements by the client indicates an understanding of the teaching?

• A. I can place an oval corn pad over toes that have corns as long as I remove the pad weekly
• B. I should soak my feet in warm water daily to soften corns and calluses
• C. I can apply lotion to soften calluses as long as I don’t put lotion between my toes
• D. I should use an over the counter liquid medication to remove corns

Correct answer: C

Rationale: Applying lotion to the feet, avoiding between toes, is correct; over-the-counter treatments and soaking are not recommended.

3. A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vitals every 15 minutes and call him back in 1 hour. From a legal perspective, which of the following actions should the nurse take next?

• A. Notify the nursing manager.
• B. Document the client's condition and communication with the surgeon.
• C. Administer additional fluids as per standard procedure.
• D. Call the surgeon back immediately to ensure timely intervention.

Correct answer: B

Rationale: In this scenario, the nurse should choose option B, which is to document the client's condition and communication with the surgeon. By documenting the client's condition and the communication with the surgeon, the nurse ensures legal protection and maintains continuity of care. This documentation serves as evidence of the actions taken, communication exchanged, and the rationale behind decisions made. Option A, notifying the nursing manager, may not be necessary at this stage unless there are specific institutional protocols requiring it. Administering additional fluids without further clarification may not be appropriate and could worsen the client's condition if not indicated. Calling the surgeon back immediately (option D) may disrupt the agreed-upon plan of action and fail to follow the surgeon's instructions of reassessment after an hour.

4. A healthcare professional is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the professional will improve the clients' commitment to a long-term goal of weight loss?

• A. Help the clients increase their self-motivation
• B. Recommend gradual dietary changes tailored to the clients' preferences
• C. Emphasize the importance of both exercise and dietary changes
• D. Encourage setting both short-term and long-term goals

Correct answer: A

Rationale: Helping the clients increase their self-motivation is crucial for long-term weight loss success. By empowering clients to find their internal drive to make healthy choices, they are more likely to stay committed to their goals. Choice B is incorrect because recommending a strict diet plan immediately may not consider the clients' individual preferences and needs, leading to potential disengagement. Choice C is incorrect as focusing solely on exercise without addressing dietary changes does not provide a comprehensive approach to weight loss. Choice D is incorrect because setting only short-term goals may not foster sustained progress towards achieving a healthier weight.

5. A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse's action:

• A. May result in charges of unlawful seclusion and restraint
• B. Leaves the nurse vulnerable to charges of assault and battery
• C. Was appropriate given the client's history of violence
• D. Was necessary to maintain the therapeutic milieu of the unit

Correct answer: A

Rationale: Placing a client in seclusion without proper justification and documentation can lead to charges of unlawful seclusion and restraint, regardless of the client's compliance. This legal issue arises from the potential violation of the client's rights and must be avoided. Choice B is incorrect as the situation does not involve assault and battery. Choice C is incorrect as past violence alone does not justify seclusion without immediate risk. Choice D is incorrect as seclusion should be used based on individual risk and necessity, not solely for maintaining the therapeutic milieu.

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