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. The nurse is caring for a client with a history of myocardial infarction who is experiencing chest pain. Which diagnostic test should the nurse anticipate preparing the client for first?

• A. Electrocardiogram (ECG)
• B. Chest X-ray
• C. Arterial blood gases (ABGs)
• D. Echocardiogram

Correct answer: A

Rationale: Corrected Rationale: An electrocardiogram (ECG) should be performed first to assess for cardiac ischemia in a client with a history of myocardial infarction and chest pain. An ECG provides immediate information about the heart's electrical activity, helping to identify changes indicative of cardiac ischemia or infarction. Chest X-ray (Choice B) is not the initial diagnostic test for assessing chest pain related to myocardial infarction. Arterial blood gases (Choice C) are used to assess oxygenation and acid-base balance but are not the primary diagnostic test for myocardial infarction. An echocardiogram (Choice D) may provide valuable information about cardiac structure and function, but it is not the first-line diagnostic test for acute chest pain in a client with a history of myocardial infarction.

3. An older female client tells the nurse that her muscles have gradually been getting weaker over time. What is the best initial response by the nurse?

• A. Explain that this is an expected occurrence with aging.
• B. Observe the lower extremities for signs of muscle atrophy.
• C. Review the medical record for recent diagnostic test results.
• D. Ask the client to describe the changes that have occurred.

Correct answer: D

Rationale: The best initial response by the nurse should be to ask the client to describe the changes that have occurred. This open-ended question allows the nurse to gather valuable information directly from the client, aiding in assessing the situation accurately and formulating an appropriate care plan. Choice A is incorrect as assuming muscle weakness is an expected occurrence with aging without further assessment may overlook potential underlying issues. Choice B is premature as it jumps straight to physical examination without first gathering subjective data. Choice C is unnecessary at this point as reviewing diagnostic test results should come after initial assessment and data collection from the client.

4. When a client with a history of atrial fibrillation is admitted with a new onset of confusion, which diagnostic test should the nurse anticipate preparing the client for first?

• A. Electrocardiogram (ECG)
• B. Chest X-ray
• C. Arterial blood gases (ABGs)
• D. Echocardiogram

Correct answer: A

Rationale: The correct answer is an Electrocardiogram (ECG). When a client with a history of atrial fibrillation presents with new-onset confusion, an ECG is crucial to assess for cardiac ischemia, which could be a potential cause of the confusion. A chest X-ray (Choice B) is not typically the first-line diagnostic test for evaluating confusion in a client with atrial fibrillation. Arterial blood gases (ABGs) (Choice C) are more useful in assessing oxygenation and acid-base balance rather than the cause of confusion in this scenario. While an echocardiogram (Choice D) provides valuable information about cardiac structure and function, it is usually not the initial diagnostic test needed in the evaluation of acute confusion in a client with atrial fibrillation.

5. A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amounts of liquid stool. Which action should the nurse implement?

• A. Digitally check the client for a fecal impaction
• B. Administer a laxative to stimulate bowel movement
• C. Increase fluid intake to soften stool
• D. Perform a digital rectal examination

Correct answer: A

Rationale: The correct action for the nurse to implement is to digitally check the client for a fecal impaction. In this scenario, the client's presentation of frequent small amounts of liquid stool after a period of no bowel movement suggests a possible impaction. By performing a digital examination, the nurse can assess for the presence of a blockage that may be causing the symptoms. Administering a laxative (Choice B) without assessing for impaction can worsen the situation. Increasing fluid intake (Choice C) is generally beneficial for bowel health but may not address the immediate issue of a potential impaction. Performing a digital rectal examination (Choice D) is similar to Choice A but is more focused on assessing the rectum itself rather than checking for an impaction.

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