Nursing Elites

1. During the admission assessment of an underweight adolescent with depression on a psychiatric unit, the nurse finds a potassium level of 2.9 mEq/dl. Which finding requires notification to the healthcare provider?

• A. Potassium level of 2.9 mEq/dl.
• B. BP of 110/70 mmHg.
• C. WBC of 10,000 mm³.
• D. Body mass index of 21.

Correct answer: A

Rationale: A potassium level of 2.9 mEq/dl is critically low, indicating hypokalemia, which can lead to serious complications such as cardiac arrhythmias. Prompt notification to the healthcare provider is essential for immediate intervention. Choice B, a blood pressure of 110/70 mmHg, is within the normal range. Choice C, a white blood cell count of 10,000 mm³, is also within normal limits and is not a concerning finding in this context. Choice D, a body mass index of 21, may indicate being underweight but is not as urgent as addressing the critically low potassium level.

2. An adolescent with a history of bipolar disorder is hospitalized during a manic episode. Which intervention is most appropriate for the nurse to include in the care plan?

• A. Encourage high levels of physical activity.
• B. Provide a quiet and structured environment.
• C. Engage the client in creative arts activities.
• D. Allow the client to make decisions about their schedule.

Correct answer: B

Rationale: During a manic episode, individuals with bipolar disorder may experience heightened energy levels, decreased need for sleep, and racing thoughts. Providing a quiet and structured environment is crucial in managing these symptoms as it helps reduce external stimuli, prevent overstimulation, and promote a sense of calmness. Encouraging high levels of physical activity may exacerbate the manic symptoms by further increasing stimulation and excitement. Engaging the client in creative arts activities might be beneficial during stable periods but may not be the most appropriate intervention during a manic episode. Allowing the client to make decisions about their schedule could potentially lead to impulsivity and poor judgment, which are common characteristics of mania.

3. The occupational health nurse is working with a female employee who was just notified that her child was involved in a motor vehicle accident (MVA) and taken to the hospital. The employee states, “I can’t believe this. What should I do?” Which response is best for the nurse to provide in this crisis?

• A. Tell me what you think should be done.
• B. How serious was the collision?
• C. What do you think you should do?
• D. Call for transportation to the hospital.

Correct answer: D

Rationale: In a crisis situation where the female employee's child is involved in a motor vehicle accident (MVA) and taken to the hospital, the most appropriate response for the nurse is to provide immediate practical assistance. Calling for transportation to the hospital ensures that the employee can quickly reach her child in need of urgent medical attention. The other options (A, B, and C) do not address the immediate need for assistance and may not provide the necessary support required in such a critical situation.

4. The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. What information should the nurse explore in-depth with the client based on this screening tool?

• A. Cancer screening result and gastritis daily alcohol intake.
• B. Consumption, liver enzyme gastrointestinal complaints, and bleeding.
• C. Efforts to cut down, annoyance with questions, guilt, and drinking as an eye-opener.
• D. Minimizes drinking, frequently misses family events, guilt about drinking, and amount of daily intake.

Correct answer: C

Rationale: The CAGE questionnaire focuses on the client’s self-perception and behaviors related to drinking, such as efforts to cut down and guilt.

5. A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into other clients' rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?

• A. Wanders into clients' rooms.
• B. Refuses antipsychotic medication.
• C. Talks with nonsensical words.
• D. Disrupts group activities.

Correct answer: D

Rationale: The correct answer is D. Disrupting group activities is a significant behavior that can pose risks to both the client and others. When combined with talking nonsensically and wandering into other clients' rooms, it indicates a need for constant observation to prevent harm or injury. Choices A, B, and C, although concerning, do not directly address the immediate safety concerns presented by disruptive behavior during group activities, which can lead to unpredictable situations and potential harm.

Similar Questions