Nursing Elites

1. An 85-year-old male resident of an extended care facility reaches for the hand of an unlicensed assistive personnel (UAP) and tries to kiss her hand several times during his morning care. The UAP reports the incident to the charge nurse. What is the best assessment of the situation?

• A. This behavior can be considered sexual harassment and should be reported to the administration immediately.
• B. The UAP should be reassigned to another group of residents, preferably females only.
• C. The client may be suffering from touch deprivation and needs to know appropriate ways to express his need.
• D. The resident needs to understand the rules regarding unwanted touching of the staff and the consequences.

Correct answer: C

Rationale: In this scenario, the resident's actions of reaching for the UAP's hand and trying to kiss it could indicate a need for touch rather than intentional sexual harassment. The best assessment is to consider the possibility that the client may be experiencing touch deprivation and is seeking appropriate ways to express his need for physical contact. Providing guidance on acceptable ways to seek physical affection can help address the underlying issue and improve the resident's interactions with the staff. Choice A is incorrect because assuming sexual harassment without understanding the context and potential reasons behind the behavior can lead to misinterpretation. Choice B is inappropriate as reassignment based on gender is not a solution and does not address the root cause of the behavior. Choice D is not the best approach as it focuses solely on setting boundaries without considering the resident's underlying need for touch.

2. A client with type 1 diabetes mellitus is admitted with hyperglycemia. Which laboratory result requires the most immediate intervention?

• A. Serum glucose of 350 mg/dL.
• B. Serum potassium of 2.8 mEq/L.
• C. Serum sodium of 136 mEq/L.
• D. Serum bicarbonate of 20 mEq/L.

Correct answer: B

Rationale: A serum potassium level of 2.8 mEq/L is critically low and can cause cardiac arrhythmias, requiring immediate intervention. Hypokalemia is a life-threatening condition that needs prompt correction to prevent serious complications. High serum glucose levels (choice A) are a concern in diabetes but do not pose an immediate life-threatening risk compared to severe hypokalemia. Serum sodium (choice C) and serum bicarbonate levels (choice D) are within normal ranges and do not require immediate intervention.

3. The client with newly diagnosed osteoporosis is being taught by the nurse about dietary modifications. Which instruction should the nurse include?

• A. Increase your intake of high-calcium foods.
• B. Limit your intake of vitamin D-rich foods.
• C. Avoid foods high in phosphorus.
• D. Increase your intake of high-sodium foods.

Correct answer: A

Rationale: Increasing the intake of high-calcium foods is essential for improving bone density and managing osteoporosis. Calcium is a key mineral necessary for bone health, and individuals with osteoporosis often need higher levels of calcium to help strengthen their bones and prevent further bone loss. Therefore, advising the client to increase their intake of high-calcium foods is the most appropriate dietary modification to support their bone health.

4. After a client with ascites due to liver cirrhosis undergoes a paracentesis, what should the nurse do post-procedure?

• A. Encourage the client to drink plenty of fluids
• B. Monitor the client's blood pressure and heart rate
• C. Position the client flat on their back
• D. Administer a dose of furosemide

Correct answer: B

Rationale: Post-paracentesis, monitoring the client's blood pressure and heart rate is crucial as it helps in early detection of potential complications such as hypotension or bleeding. This close observation enables timely intervention and ensures the client's safety.

5. A client with a new diagnosis of myasthenia gravis is prescribed pyridostigmine (Mestinon). Which instruction should the nurse include in the client's teaching?

• A. Take the medication with food to prevent gastrointestinal upset.
• B. Take the medication 30 minutes before meals.
• C. Avoid dairy products while taking this medication.
• D. Take the medication at bedtime.

Correct answer: B

Rationale: The correct instruction for a client with myasthenia gravis prescribed pyridostigmine (Mestinon) is to take the medication 30 minutes before meals. This timing is crucial as it helps improve muscle strength for eating and swallowing. By taking the medication before meals, the client can experience enhanced muscle function during mealtime, which is especially important for managing the symptoms of myasthenia gravis. Choices A, C, and D are incorrect. Taking the medication with food may decrease its effectiveness, avoiding dairy products is not necessary, and taking the medication at bedtime does not coincide with the optimal timing for enhancing muscle function during meals.

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