Nursing Elites

1. An adult female client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. After starting medication therapy, the nurse notices the client has more energy, is giving away her belongings, and has an elevated mood. Which intervention is best for the nurse to implement?

• A. Support the client by telling her what wonderful progress she is making.
• B. Ask the client if she has had any recent thoughts of harming herself.
• C. Reassure the client that the antidepressant drugs are apparently effective.
• D. Tell the client to keep her belongings because she will need them at discharge.

Correct answer: B

Rationale: When a client with major depressive disorder shows signs of increased energy, giving away belongings, and an elevated mood, it could indicate a shift towards suicidal behavior. Therefore, the best intervention for the nurse is to ask the client if she has had any recent thoughts of harming herself. This is crucial to assess the client's risk for suicide and provide necessary interventions. Choices A, C, and D are incorrect because they do not address the potential risk of harm to the client and do not prioritize the immediate assessment required in this situation.

2. After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take first?

• A. Slide the stethoscope across the sternum.
• B. Move the stethoscope to the mitral site.
• C. Listen with the bell at the same location.
• D. Observe the cardiac telemetry monitor.

Correct answer: C

Rationale: The nurse uses the bell of the stethoscope to hear low-pitched sounds such as S3 and S4. To determine if an S3 heart sound is present, the nurse should listen at the same location using the bell first. This allows for the accurate identification of low-pitched sounds. Moving the stethoscope across the sternum (Choice A) or to the mitral site (Choice B) would not be the initial actions to assess for an S3 heart sound. Observing the cardiac telemetry monitor (Choice D) is not relevant for assessing S3 heart sounds, as it does not provide direct auscultation of heart sounds.

3. While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?

• A. Elevated blood pressure must be anticipated and identified quickly
• B. Frequent monitoring helps ensure the medication is effective
• C. It is standard protocol for all hospitalized children
• D. We need to monitor for any potential kidney damage

Correct answer: A

Rationale: The correct answer is A: 'Elevated blood pressure must be anticipated and identified quickly.' Acute glomerulonephritis can lead to significant hypertension, making it crucial to monitor blood pressure frequently to promptly identify any elevation. Choice B is incorrect because while monitoring can help assess medication effectiveness, the primary reason for frequent blood pressure checks in this case is to detect elevated blood pressure. Choice C is incorrect as not all hospitalized children require such frequent blood pressure monitoring. Choice D is incorrect as the primary reason for monitoring blood pressure is to detect hypertension, rather than solely focusing on potential kidney damage.

4. A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse's decision to hold the client's scheduled antihypertensive medication?

• A. Increased urinary clearance of the multiple medications has produced diuresis and lowered the blood pressure
• B. The antagonistic interaction among the various blood pressure medications has reduced their effectiveness
• C. The additive effect of multiple medications has caused the blood pressure to drop too low.
• D. The synergistic effect of the multiple medications has resulted in drug toxicity and resulting hypotension.

Correct answer: C

Rationale: When medications with a similar action are administered, an additive effect occurs that is the sum of the effects of each medication. In this case, several medications that all lower blood pressure, when administered together, resulted in hypotension.

5. The nurse is caring for a 17-year-old male who fell 20 feet 5 months ago while climbing the side of a cliff and has been in a sustained vegetative state since the accident. Which intervention should the nurse implement?

• A. Talk directly to the adolescent while providing care
• B. Maintain silence during care to avoid overstimulation
• C. Play soothing music in the background
• D. Limit visitors to immediate family only

Correct answer: A

Rationale: Talking directly to the adolescent is the most appropriate intervention in this scenario. It helps maintain a sense of connection and respect, even if the response is not evident. Maintaining silence may lead to isolation and hinder any potential communication attempts. Playing soothing music may not provide the personal interaction needed for connection. Limiting visitors to immediate family only may deprive the patient of diverse interactions that could be beneficial for their emotional well-being.

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