Nursing Elites

1. An adult male is admitted to the psychiatric unit from the emergency department because he is in the manic disorder. He has lost 10 pounds in the last two weeks and has not bathed in a week because he has been 'trying to start a new business' and is 'too busy to eat.' He is alert and oriented to time, place and person, but not situation. Which nursing diagnosis has the greatest priority?

• A. Self-care deficit
• B. Disturbed sleep pattern
• C. Disturbed thought processes
• D. Imbalanced nutrition

Correct answer: D

Rationale: Imbalanced nutrition is the most critical nursing diagnosis to address in this scenario. The patient's significant weight loss and neglect of basic needs, such as eating and personal hygiene, indicate a severe imbalance in nutrition. Addressing this issue is crucial to prevent further health deterioration. Self-care deficit, disturbed sleep pattern, and disturbed thought processes are important but secondary concerns compared to the immediate risk posed by imbalanced nutrition. While self-care deficit and disturbed sleep pattern are valid concerns, the patient's weight loss and neglect of basic needs take precedence. Disturbed thought processes are also significant but addressing the imbalanced nutrition is more urgent in this context.

2. A 17-year-old female is seen in the school clinic for an evaluation of abdominal pain and dysmenorrhea. The client's last menstrual period was 3 weeks ago, and her vital signs are within normal limits. Which action should the nurse take first?

• A. Refer the client to a healthcare provider for a pelvic examination
• B. Notify the parents that the client needs to be picked up from school
• C. Determine the date of the client's last menstrual period
• D. Ask the client to lie down for a pelvic examination

Correct answer: A

Rationale: The correct action the nurse should take first is to refer the client to a healthcare provider for a pelvic examination. This is important to rule out serious conditions that may be causing the abdominal pain and dysmenorrhea. While notifying the parents, determining the date of the client's last menstrual period, and asking the client to lie down for a pelvic examination could be necessary steps, the priority is to ensure a proper evaluation by a healthcare provider to address the client's presenting symptoms effectively.

3. A female client on the mental health unit tells the nurse that her roommate is sitting on the bathroom floor with superficial cuts on her wrists. The nurse cleans and assesses the client's wrists and asks what happened. She doesn't respond. What should the nurse do next?

• A. Find supplies to put a dressing on the client's wrists
• B. Take the client to a room for supervision by staff
• C. Call the healthcare provider to report the client's behavior
• D. Go find a staff member to stay in the room with the client

Correct answer: B

Rationale: In this situation, the nurse should prioritize the safety of the client. Taking the client to a room for supervision by staff is crucial to ensure immediate safety and further assessment of the client's condition. While cleaning and assessing the client's wrists are important, ensuring ongoing safety and monitoring by staff is the priority. Calling the healthcare provider at this moment may cause delays in providing immediate assistance. Finding supplies to put a dressing on the client's wrists can wait until the client is in a safe environment. Therefore, option B is the best course of action to address the client's safety needs promptly.

4. The nurse is preparing to administer medications to a client with a nasogastric tube. Which action should the nurse take first?

• A. Check for tube placement
• B. Crush the medications
• C. Flush the tube with water
• D. Administer the medications

Correct answer: A

Rationale: The correct first action when administering medications to a client with a nasogastric tube is to check for tube placement. This is crucial to ensure that the medications are delivered to the correct location within the gastrointestinal tract. Checking the tube placement helps prevent complications such as medication entering the lungs if the tube is misplaced. Crushing the medications (choice B) or flushing the tube with water (choice C) should only be done after confirming the correct tube placement. Administering the medications (choice D) without verifying the tube placement can lead to serious consequences.

5. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 4 liters per minute via nasal cannula. The client becomes lethargic and confused. What action should the nurse take first?

• A. Decrease the oxygen flow rate
• B. Increase the oxygen flow rate
• C. Encourage the client to cough and deep breathe
• D. Monitor the client's oxygen saturation level

Correct answer: A

Rationale: In this scenario, the priority action for the nurse is to decrease the oxygen flow rate. Clients with COPD are sensitive to high levels of oxygen and can develop oxygen toxicity, leading to symptoms like lethargy and confusion. Decreasing the oxygen flow rate helps prevent this complication. Increasing the oxygen flow rate would worsen the client's condition. Encouraging coughing and deep breathing may not address the immediate issue of oxygen toxicity. While monitoring the client's oxygen saturation level is important, taking action to address the oxygen toxicity by decreasing the flow rate is the priority in this situation.

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