Nursing Elites

1. When should the charge nurse intervene based on the observed behavior?

• A. Two staff members are overheard talking about a cure for AIDS outside a client's room.
• B. A hospital transporter is reading a client's history and physical while waiting for an elevator.
• C. A UAP tells a client, 'It's hard to quit drinking but Alcoholics Anonymous helped me.'
• D. Two visitors are discussing a hospitalized client's history of drug abuse in the visitor's lounge.

Correct answer: B

Rationale: The hospital transporter reading a client's history and physical without a legitimate need violates patient confidentiality. This behavior requires immediate intervention to protect the client's privacy and confidentiality rights.

2. An elderly male client reports to the clinic nurse that he is experiencing increasing nocturia with difficulty initiating his urine stream. He reports a weak urine flow and frequent dribbling after voiding. Which nursing action should be implemented?

• A. Obtain a urine specimen for culture and sensitivity.
• B. Encourage the client to schedule a digital rectal exam.
• C. Advise the client to maintain a voiding diary for one week.
• D. Instruct the client in effective techniques for cleansing the glans penis.

Correct answer: B

Rationale: Encouraging the client to schedule a digital rectal exam is the most appropriate nursing action in this situation. This exam can help evaluate for potential prostate enlargement or other issues contributing to the urinary symptoms described by the client. It is important to assess the prostate gland for any abnormalities that may be causing the urinary issues reported by the client.

3. A client who has been receiving treatment for depression with a selective serotonin reuptake inhibitor (SSRI) reports experiencing decreased libido. What is the best response by the nurse?

• A. Decreased libido is a common side effect of SSRIs and may improve over time.
• B. I will notify your healthcare provider to discuss possible medication changes.
• C. You should take your medication with food to reduce side effects.
• D. Increase your daily exercise to help manage this side effect.

Correct answer: B

Rationale: When a client reports experiencing decreased libido while taking SSRIs, it is important for the nurse to notify the healthcare provider to discuss potential medication adjustments. This side effect can significantly impact a client's quality of life, and addressing it promptly by involving the healthcare provider is crucial in providing holistic care. Choices A, C, and D do not directly address the issue of decreased libido caused by SSRIs. Simply waiting for improvement over time, altering the administration of medication with food, or increasing exercise are not appropriate strategies for managing this specific side effect.

4. A client's health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn disease, rather than ulcerative colitis, as the cause of the client's signs and symptoms?

• A. A pattern of distinct exacerbations and remissions
• B. Severe diarrhea
• C. An absence of blood in stool
• D. Involvement of the rectal mucosa

Correct answer: C

Rationale: In the context of inflammatory bowel disease, the absence of blood in stool is more indicative of Crohn disease. Crohn disease typically presents with non-bloody stools, while ulcerative colitis often involves bloody stools due to continuous mucosal inflammation confined to the colon and rectum.

5. Why is a client with ascites scheduled for a paracentesis procedure?

• A. To diagnose liver disease
• B. To relieve abdominal pressure
• C. To assess kidney function
• D. To reduce blood pressure

Correct answer: B

Rationale: The correct answer is B: "To relieve abdominal pressure." Paracentesis is performed to drain accumulated fluid in the peritoneal cavity, providing symptomatic relief for clients with ascites. Choice A is incorrect because paracentesis is not a diagnostic procedure for liver disease. Choice C is incorrect as assessing kidney function would typically involve different procedures. Choice D is incorrect as paracentesis does not directly impact blood pressure.

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