Nursing Elites

1. What might be signaled when a client tells the nurse to 'pray for me' and entrusts her wedding ring to the nurse?

• A. Anxiety
• B. Suicidal ideation
• C. Major depression
• D. Hopelessness

Correct answer: B

Rationale: The client entrusting the wedding ring and asking the nurse to pray for them can be indicative of suicidal ideation. This behavior suggests a deep level of distress and hopelessness, potentially leading to suicidal thoughts or actions. While anxiety is a common emotion, the act of entrusting personal items and making requests like praying for them go beyond typical anxiety symptoms. Major depression can be associated with suicidal ideation, but the specific actions described in this scenario point more towards suicidal thoughts. Hopelessness, while related to suicidal ideation, is a broader concept that does not capture the specific cues given by the client in this scenario, making it a less accurate choice.

2. The nurse is discussing the need for early diagnosis and treatment of autism spectrum disorder (ASD) with parents of children suspected of having the condition. Which statement should the nurse include?

• A. Early diagnosis and treatment provide the only means for a cure of ASD.
• B. Early diagnosis and treatment gives your child the best chance of becoming a fully functioning adult.
• C. Early diagnosis and treatment provides the best way to ensure that your child can be admitted to an assisted living facility as an adult.
• D. Early diagnosis and treatment prevent your child from developing any other mental condition.

Correct answer: B

Rationale: The correct statement for the nurse to include is that early diagnosis and treatment provide the best chance for the child to become a fully functioning adult. It is important to educate parents that while early intervention can improve outcomes for individuals with ASD, it does not offer a cure but helps in managing symptoms and developing necessary skills. Choice A is incorrect as there is currently no cure for ASD. Choice C is inaccurate as early diagnosis and treatment focus on improving the child's quality of life and independence rather than ensuring admission to an assisted living facility. Choice D is incorrect as early diagnosis and treatment of ASD do not prevent the development of other mental health conditions; however, they can help in identifying and managing such conditions early on.

3. At the beginning of her shift in a long-term care facility, which of the following clients should a nurse check on first?

• A. A 91-year-old man who needs help eating breakfast
• B. An 86-year-old man who has been incontinent in his bed
• C. An 82-year-old woman who needs IV antibiotics
• D. A 75-year-old man who is recovering from an injury and needs an ice pack

Correct answer: C

Rationale: When prioritizing care in a long-term care facility, the nurse must consider tasks that require their immediate attention and cannot be delegated. Administering IV antibiotics is a critical nursing task that only the nurse can perform, ensuring the timely and correct delivery of medication to the patient. While assisting with breakfast, managing incontinence, and providing an ice pack are important, these tasks can be delegated to other healthcare team members, allowing the nurse to address the client needing IV antibiotics first to ensure effective treatment and patient safety.

4. A 58-year-old client is being tested for rheumatoid arthritis. Her physician orders an erythrocyte sedimentation rate (ESR). Which of the following results is most likely to be associated with arthritis?

• A. 5 mm/hr
• B. 12 mm/hr
• C. 28 mm/hr
• D. 40 mm/hr

Correct answer: D

Rationale: The erythrocyte sedimentation rate (ESR) measures levels of inflammation in the body. Elevated ESR levels are commonly seen in autoimmune conditions like rheumatoid arthritis due to the presence of inflammation. In women over 50 years old, a normal ESR is typically below 30 mm/hr. Therefore, a result of 40 mm/hr is more indicative of arthritis in a 58-year-old individual. Choices A, B, and C are below the normal ESR range for a woman of this age and would not be as strongly associated with arthritis.

5. Jaime has a diagnosis of schizophrenia with negative symptoms. In planning care for the client, Nurse Brienne would anticipate a problem with:

• A. Auditory hallucinations
• B. Bizarre behaviors
• C. Ideas of reference
• D. Motivation for activities

Correct answer: D

Rationale: In clients with negative symptoms of schizophrenia, such as Jaime, a common problem is avolition, which is the lack of motivation for activities. These 'negative' symptoms are characterized by inexpressive faces, blank looks, monotone speech, few gestures, and a seeming lack of interest in the world. Patients may also experience an inability to feel pleasure or act spontaneously. It is crucial to differentiate between the lack of expression and lack of feeling, as well as between lack of will and lack of activity. Auditory hallucinations (choice A) are positive symptoms, not typically associated with negative symptoms of schizophrenia. Bizarre behaviors (choice B) are more aligned with positive symptoms like disorganized behavior. Ideas of reference (choice C) involve incorrectly interpreting casual incidents and external events as having direct reference to oneself, which is not directly related to motivation for activities seen in negative symptoms.

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