Nursing Elites

1. When a staff member is observed not following the plan of care for a client with an antisocial personality disorder, what should the nurse do?

• A. confront the staff member immediately and say, "You know that is not the treatment plan."?
• B. write an incident report to create a paper trail of the staff member's failure to follow the planned program.
• C. ask the staff member to talk in private, and reinforce how antisocial clients try to divide staff.
• D. bring up the incident during the weekly conference so that this staff member is not assigned to work with antisocial persons again.

Correct answer: C

Rationale: When a staff member is observed not following the plan of care for a client with an antisocial personality disorder, it is crucial to address the issue promptly and effectively. Confronting the staff member immediately in front of the client may worsen the situation by enhancing the division of staff and compromising client care. Writing an incident report, although important for documentation, may not address the immediate need to correct the behavior. Bringing up the incident during a weekly conference may not be the most effective approach for immediate resolution. Asking the staff member to talk in private and reinforcing how antisocial clients try to divide staff is the best option. This approach allows for a constructive conversation to address the issue, provide education, and help the staff member develop skills to work effectively with this client population.

2. When assessing a client with glaucoma, a nurse expects which of the following findings?

• A. Complaints of double vision
• B. Complaints of halos around lights
• C. Intraocular pressure of 15 mm Hg
• D. Soft globe on palpation

Correct answer: B

Rationale: When assessing a client with glaucoma, a common finding is complaints of halos around lights. Other symptoms of glaucoma include loss of peripheral vision or blind spots, reddened sclera, firm globe, decreased accommodation, and occasional eye pain. Glaucoma may be asymptomatic until permanent damage to the optic nerve and retina occurs. Double vision is not a typical symptom of glaucoma. In terms of intraocular pressure, normal levels range from 10 to 21 mm Hg, making an intraocular pressure of 15 mm Hg within the normal range. A soft globe on palpation is not a typical finding in glaucoma.

3. When assessing a client for risk of hyperphosphatemia, which piece of information is most important for the nurse to obtain?

• A. A history of radiation treatment in the neck region
• B. A history of recent orthopedic surgery
• C. A history of minimal physical activity
• D. A history of the client's food intake

Correct answer: A

Rationale: The correct answer is a history of radiation treatment in the neck region. Previous radiation to the neck may have damaged the parathyroid glands, which are crucial for calcium and phosphorus regulation. This damage can lead to disruptions in phosphorus levels, increasing the risk of hyperphosphatemia. Choices B, C, and D are not as directly related to phosphorus regulation. Orthopedic surgery, minimal physical activity, and food intake are more closely associated with calcium levels rather than phosphorus regulation. Therefore, it is essential for the nurse to focus on obtaining information about a history of radiation treatment in the neck region when assessing the risk of hyperphosphatemia in a client.

4. Before administering Theodur to a 10-year-old being treated for asthma, the nurse should check the:

• A. Urinary output
• B. Blood pressure
• C. Pulse
• D. Temperature

Correct answer: C

Rationale: The correct answer is to check the pulse. Theodur is a bronchodilator used in asthma treatment, and one of the side effects is tachycardia (increased heart rate). Therefore, it is essential to assess the pulse rate before administering Theodur to monitor for any potential tachycardia. Checking urinary output (Choice A), blood pressure (Choice B), and temperature (Choice D) are not directly related to the immediate side effects of bronchodilators like Theodur in this context, making them unnecessary assessments.

5. Ashley and her boyfriend Chris, both 19 years old, are transported to the Emergency Department after being involved in a motorcycle accident. Chris is badly hurt, but Ashley has no apparent injuries, though she appears confused and has trouble focusing on what is going on around her. She complains of dizziness and nausea. Her pulse is rapid, and she is hyperventilating. The nurse should assess Ashley's level of anxiety as:

• A. mild.
• B. moderate.
• C. severe.
• D. panic.

Correct answer: C

Rationale: Based on the symptoms described, Ashley's level of anxiety should be assessed as severe. In severe anxiety, individuals have difficulty solving problems and understanding their environment. They often exhibit somatic symptoms like dizziness, nausea, rapid pulse, and hyperventilation. In contrast, mild anxiety may lead to mild discomfort or even enhanced performance. Moderate anxiety involves grasping less information, mild difficulty in problem-solving, and slight changes in vital signs. Panic, on the other hand, is characterized by markedly disturbed behavior and a potential loss of touch with reality. Therefore, in Ashley's case, the presence of somatic symptoms and vital sign changes indicates severe anxiety.

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