Nursing Elites

1. The PN is caring for a client with schizophrenia who continues to repeat the last words heard. Which nursing problem should the PN document in the medical record?

• A. Altered thought processes
• B. Impaired social interaction
• C. Risk for self-directed violence
• D. Disturbed thought processes

Correct answer: D

Rationale: The correct answer is D: Disturbed thought processes. Echolalia, the repetition of heard words, is associated with disturbed thought processes, which are commonly seen in schizophrenia. Altered thought processes (Choice A) is a generic term and does not specifically address the behavior of repeating words. Impaired social interaction (Choice B) is not the primary concern when a client repeats the last words heard. Risk for self-directed violence (Choice C) is not directly related to the behavior of repeating words but focuses on the potential harm the client may cause to themselves.

2. An 8-year-old is placed in 90-90 traction for a fractured femur resulting from a motor vehicle collision. Which finding requires further action by the nurse?

• A. No bowel movement for two days
• B. Mother assists child in changing positions
• C. Weights are touching the foot of the bed
• D. Child is able to move the toes freely when tickled

Correct answer: C

Rationale: The correct answer is C. In 90-90 traction, the weights should hang freely and not touch the foot of the bed to maintain proper traction and bone alignment. Option A is not necessarily a concern as bowel movements can be influenced by various factors, including diet changes and pain medication. Option B indicates good caregiver involvement, promoting comfort and preventing complications. Option D demonstrates neurovascular function, which is a positive finding. Therefore, the weights touching the foot of the bed is the finding that requires immediate attention to ensure the effectiveness of the traction.

3. A client with a recent total knee replacement is scheduled for physical therapy. The client refuses to participate, stating that the pain is too intense. What should the nurse do first?

• A. Administer the prescribed analgesic and encourage participation after it takes effect.
• B. Reschedule the physical therapy session for later in the day.
• C. Explain the importance of physical therapy for recovery.
• D. Notify the physical therapist of the client's refusal.

Correct answer: A

Rationale: Administering pain medication before physical therapy helps manage the pain, making it easier for the client to participate in the necessary exercises to improve recovery and prevent complications such as joint stiffness. Choice B is not the first step as addressing the pain should take precedence. Choice C is important but should come after managing the pain to facilitate participation. Choice D involves another healthcare provider and is not the immediate action needed in this situation.

4. Which neurotransmitter is most closely associated with mood regulation and is targeted by antidepressants?

• A. Serotonin
• B. Dopamine
• C. GABA
• D. Acetylcholine

Correct answer: A

Rationale: The correct answer is A: Serotonin. Serotonin plays a vital role in mood regulation, and its imbalance is often associated with depression. Many antidepressants function by boosting serotonin levels in the brain. Dopamine (Choice B) is more linked to reward and pleasure pathways in the brain, not primarily targeted for mood regulation. GABA (Choice C) is an inhibitory neurotransmitter that helps reduce neuronal excitability, not primarily associated with mood regulation. Acetylcholine (Choice D) is involved in muscle movement and cognitive functions, not the primary target of antidepressants for mood regulation.

5. At the end of a 12-hour shift, the PN observes the urine in a client's drainage bag as seen in the picture. Which action should the PN take next?

• A. Offer to administer a prescribed PRN analgesic
• B. Obtain a finger stick capillary glucose level
• C. Determine if the client's bladder feels distended
• D. Note the most recent white blood cell count

Correct answer: D

Rationale: Noting the white blood cell count is the most appropriate action in this situation. Changes in urine appearance could indicate infection, and assessing the white blood cell count helps in evaluating the possibility of infection. This is crucial for understanding the client's overall condition. The other options are not directly related to assessing infection based on urine appearance. Offering analgesics, checking glucose levels, or determining bladder distention may not address the underlying issue of a potential infection.

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