Nursing Elites

1. The manic client has just interrupted the group session with the counselor for the 4th time, explaining that she already knows this information on 'dealing with others when you are down' and constantly gets up and goes to the front. What should the nurse do at this time?

• A. Engage the client to walk with you to make another pot of coffee
• B. Ask the client to reflect on their behavior to determine if it is appropriate
• C. Ask the group to tell the client how they feel when she interrupts
• D. Instruct the client to perform jumping jacks and count aloud to get rid of some energy

Correct answer: A

Rationale: In this situation, it is important to redirect the client's energy and focus. Engaging the client in a purposeful activity like making another pot of coffee can help distract them from disruptive behavior and provide an outlet for their excess energy. This choice also helps in maintaining a therapeutic environment by involving the client in a constructive task. Asking the client to reflect on their behavior (Choice B) might not be effective during a manic episode as the client may not be in a state to critically analyze their actions. Asking the group to tell the client how they feel (Choice C) can escalate the situation and may not be appropriate in this context. Instructing the client to perform jumping jacks and count aloud (Choice D) may not address the underlying issue of disruptive behavior and may not be suitable for the current situation.

2. Which electrolyte imbalance would be the nurse's priority concern in the burn client?

• A. Hypernatremia
• B. Hyperkalemia
• C. Hypoalbuminemia
• D. Hypermagnesemia

Correct answer: B

Rationale: The correct answer is hyperkalemia. In a burn client, the nurse's priority concern is hyperkalemia due to cell lysis, which releases potassium into the bloodstream. This can lead to dangerous levels of potassium in the blood. Hypernatremia (Choice A) is less likely in burn clients. Hypoalbuminemia (Choice C) can occur but is not the priority in the immediate management of a burn client. Hypermagnesemia (Choice D) is not typically associated with burn injuries.

3. Why must the nurse be careful not to cut through or disrupt any tears, holes, bloodstains, or dirt present on the clothing of a client who has experienced trauma?

• A. The clothing is the property of another and must be treated with care.
• B. Such care facilitates repair and salvage of the clothing.
• C. The clothing of a trauma victim is potential evidence with legal implications.
• D. Such care decreases trauma to the family members receiving the clothing.

Correct answer: C

Rationale: The correct answer is C. Trauma in any client, living or dead, has potential legal and/or forensic implications. Clothing, patterns of stains, and debris are sources of potential evidence and must be preserved. Nurses must be aware of state and local regulations that require mandatory reporting of cases of suspected child and elder abuse, accidental death, and suicide. Each Emergency Department has written policies and procedures to assist nurses and other health care providers in making appropriate reports. Physical evidence is real, tangible, or latent matter that can be visualized, measured, or analyzed. Emergency Department nurses can be called on to collect evidence. Health care facilities have policies governing the collection of forensic evidence. The chain of evidence custody must be followed to ensure the integrity and credibility of the evidence. The chain of evidence custody is the pathway that evidence follows from the time it is collected until it has served its purpose in the legal investigation of an incident. Choices A, B, and D are incorrect because they do not address the crucial aspect of preserving potential evidence with legal implications that may be present on the clothing of a trauma victim.

4. Which nursing diagnosis has the highest priority for a client with insomnia?

• A. Ineffective breathing pattern
• B. Disturbed sensory perception
• C. Ineffective coping
• D. Sleep deprivation

Correct answer: A

Rationale: The correct answer is 'A: Ineffective breathing pattern.' When a client presents with insomnia, assessing for underlying causes is crucial. Sleep apnea, an airway issue, may be a contributing factor to the client's insomnia, making 'Ineffective breathing pattern' the priority. 'Disturbed sensory perception' focuses on alterations in touch, taste, or vision, which are not directly related to insomnia. 'Ineffective coping' addresses a client's inability to manage stress, which, although important, is not the priority in this case. 'Sleep deprivation' is a consequence of insomnia rather than a primary nursing diagnosis.

5. The client with peripheral vascular disease is reviewing self-care measures. Which of the following statements indicates proper self-care measures?

• A. "I like to soak my feet in the hot tub every day."?
• B. "I walk to the mailbox in my bare feet."?
• C. "I stopped smoking and only use chewing tobacco."?
• D. "I have my wife examine the soles of my feet each day."?

Correct answer: D

Rationale: The correct answer is, "I have my wife examine the soles of my feet each day."? Clients with peripheral vascular disease should examine their feet daily for any signs of redness, dryness, or cuts. If the client is unable to do this themselves due to decreased sensation in their feet, a caregiver or family member should assist. Soaking feet in a hot tub should be avoided as the client may not be able to sense if the water is too hot, potentially causing burns. Walking barefoot can lead to injuries, so wearing shoes or slippers is recommended to minimize trauma. While quitting smoking is a positive step, using chewing tobacco can still constrict blood vessels, adversely affecting circulation in the extremities.

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