Nursing Elites

1. What does the E in the acronym DELIRIUM represent in causes contributing to delirium?

• A. EEG
• B. EKG
• C. Electrolytes
• D. Echocardiogram

Correct answer: C

Rationale: The E in the acronym DELIRIUM stands for Electrolytes. Electrolyte imbalances can lead to delirium. The other letters in the acronym represent: D = Dementia; L = Lung, liver, heart, kidney, brain; I = Infection; R = Rx Drugs; I = Injury, Pain, Stress; U = Unfamiliar environment; M = Metabolic. It is crucial to differentiate delirium from dementia, as delirium is often reversible with treatment of underlying causes. Dementia should only be considered after ruling out delirium, as addressing the contributing factors may alleviate the delirium state.

2. Which method is used to verify the placement of a newly inserted central venous access device (CVAD)?

• A. Chest x-ray
• B. Flushing the line with heparin
• C. Withdrawing blood to ensure patency
• D. Chest fluoroscopy

Correct answer: A

Rationale: The correct method to verify the placement of a newly inserted central venous access device (CVAD) is a chest x-ray. This is crucial to detect any potential complications such as pneumothorax, which can occur during subclavian vein catheter insertion. Symptoms of pneumothorax may include shortness of breath and anxiety. Flushing the line with heparin is not used for placement verification, but rather for maintaining patency after verification. Withdrawing blood to ensure patency is done after placement is confirmed, not for initial verification. Chest fluoroscopy may be used during the insertion process but is not typically employed for placement verification.

3. Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis?

• A. Perform cough and deep breathing exercises hourly.
• B. Turn from side to side in bed at least every 2 hours.
• C. Dorsiflex and plantarflex the feet 10 times each hour
• D. Drink approximately 4 ounces of water every hour

Correct answer: C

Rationale: To reduce the risk of venous thrombosis, the nurse should instruct the client to perform dorsiflexion and plantar flexion exercises regularly. These exercises help promote venous return and prevent venous thrombus formation. Options A, B, and D are beneficial in managing other complications of immobility, such as atelectasis and pressure ulcers, but they are less effective in preventing venous thrombosis compared to dorsiflexion and plantar flexion exercises.

4. The nurse who is preparing to give an adolescent client a prescribed antipsychotic medication notes that parental consent has not been obtained. Which action should the nurse take?

• A. Review the chart for a signed consent for medication administration.
• B. Get the guardian's permission to give the medication.
• C. Do not give the medication and document the reason.
• D. Complete an incident report and notify the supervisor.

Correct answer: C

Rationale: In this scenario, the correct action for the nurse to take is not to administer the medication and document the reason. Since the adolescent client is a minor, parental or guardian consent is required for medical treatment, including medication administration. Option A, reviewing the chart for a signed consent for medication administration, is not the appropriate action in this situation as the focus is on parental consent for the client. Option B is incorrect because obtaining the health care provider's permission does not replace the need for parental consent for a minor. Option D, completing an incident report and notifying the supervisor, is unnecessary as there is no adverse event to report; the key concern is the lack of parental consent for medication administration.

5. Which behavior by the client exhibits denial after a recent diagnosis?

• A. Attempts to minimize the illness
• B. Lacks an emotional response to the illness
• C. Refuses to discuss the condition with the client's spouse
• D. Expresses displeasure with the prescribed activity program

Correct answer: A

Rationale: The correct answer is 'Attempts to minimize the illness.' This behavior is a classic sign of denial, where the individual tries to downplay the seriousness of the illness to cope with it. By minimizing the illness, the client avoids facing the reality of the situation, which is characteristic of denial. Lacking an emotional response to the illness suggests suppression of emotions rather than denial. Refusing to discuss the condition with the spouse may stem from other issues like relationship strain or fear of causing distress, but it doesn't directly indicate denial. Expressing displeasure with the prescribed activity program typically reflects displaced anger, not denial of the illness.

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