Nursing Elites

1. The nurse has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis?

• A. Nutrition
• B. Elimination
• C. Activity
• D. Safety

Correct answer: D

Rationale: In caring for a client with severe depression, safety is a critical priority. The nurse must address precautions to prevent suicide as part of the care plan. While nutrition, elimination, and activity are important aspects of care, safety takes precedence due to the immediate risk of harm associated with depression. Ensuring the client's safety by implementing measures to prevent self-harm or suicide is the priority intervention. Addressing nutrition, elimination, and activity can follow once the client's safety is assured.

2. A mother has recently been informed that her child has Down syndrome. You will be assigned to care for the child at shift change. Which of the following characteristics is not associated with Down syndrome?

• A. Simian crease
• B. Brachycephaly
• C. Oily skin
• D. Hypotonicity

Correct answer: C

Rationale: Individuals with Down syndrome commonly have certain physical characteristics, such as a simian crease (single transverse palmar crease), brachycephaly (shortened front-to-back skull dimension), and hypotonicity (low muscle tone). Oily skin is not a characteristic associated with Down syndrome; instead, individuals with Down syndrome often have dry skin. Therefore, oily skin is the correct answer in this context.

3. A 64-year-old patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care?

• A. Assist with active range of motion (ROM).
• B. Observe for agitation and paranoia.
• C. Give muscle relaxants as needed to reduce spasms.
• D. Use simple words and phrases to explain procedures.

Correct answer: A

Rationale: In a patient with ALS, progressive muscle weakness is a significant issue. Assisting with active range of motion (ROM) exercises will help maintain muscle strength for as long as possible. Agitation and paranoia are not typically associated with ALS, making choice B incorrect. Giving muscle relaxants can further weaken muscles and depress respirations, worsening the condition, so choice C is inappropriate. Choice D is not directly related to the patient's physical condition and needs.

4. A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6�F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first?

• A. Codeine
• B. Guaifenesin (Robitussin)
• C. Acetaminophen (Tylenol)
• D. Piperacillin/tazobactam (Zosyn)

Correct answer: D

Rationale: The correct answer is Piperacillin/tazobactam (Zosyn). Early initiation of antibiotic therapy is crucial in cases of community-acquired pneumococcal pneumonia to reduce mortality. While providing symptomatic relief with medications like Codeine for cough, Guaifenesin for mucus clearance, and Acetaminophen for fever and pain is important, the priority should be to start antibiotic therapy to target the underlying infection. Piperacillin/tazobactam is an appropriate choice for treating severe community-acquired pneumonia caused by pneumococcal organisms.

5. What is the most frequent cause for suicide in adolescents?

• A. Progressive failure to adapt
• B. Feelings of anger or hostility
• C. Reunion wish or fantasy
• D. Feelings of alienation or isolation

Correct answer: D

Rationale: Feelings of alienation or isolation are the most frequent cause for suicide in adolescents. Adolescents may experience a gradual isolation leading to a loss of meaningful social contacts, which can be self-imposed or result from an inability to express feelings. During this developmental stage, achieving a sense of identity and peer acceptance is crucial. Choices A, B, and C are incorrect: Progressive failure to adapt, feelings of anger or hostility, and reunion wish or fantasy are not typically identified as the primary cause of suicide in adolescents.

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