Nursing Elites

1. What is the priority intervention when managing a client with delirium?

• A. Administer antipsychotic medication to calm the client
• B. Identify any reversible causes of delirium
• C. Provide a low-stimulation environment
• D. Administer sedative medication to control agitation

Correct answer: B

Rationale: The correct answer is to identify any reversible causes of delirium. Delirium is often caused by underlying issues such as infections, medication side effects, or metabolic imbalances. Addressing these root causes can help resolve delirium more effectively. Administering antipsychotic or sedative medications should not be the initial approach as they can worsen delirium in some cases. Providing a low-stimulation environment is beneficial but not the priority when reversible causes need to be addressed first.

2. A client is experiencing difficulty voiding following the removal of an indwelling catheter. What action should the nurse take to assist the client?

• A. Assess for bladder distention after 4 hours
• B. Pour warm water over the perineum
• C. Restrict the client's oral fluid intake
• D. Restrict movement for at least 12 hours

Correct answer: B

Rationale: The correct action for the nurse to assist the client who is experiencing difficulty voiding after the removal of an indwelling catheter is to pour warm water over the perineum. This technique can help stimulate urination by promoting relaxation of the perineal muscles and improving blood flow to the area. Assessing for bladder distention after 4 hours (Choice A) is important but not the immediate intervention needed to assist the client in voiding. Restricting the client's oral fluid intake (Choice C) can exacerbate the issue by reducing urine production. Restricting movement for at least 12 hours (Choice D) is unnecessary and may lead to discomfort and other complications.

3. A nurse in a long-term care facility is serving on the ethics committee, which is addressing a client care dilemma. Which of the following strategies will facilitate resolving the dilemma?

• A. Ensure client autonomy only
• B. Consider only medical benefits
• C. Ensure clear communication among the health care team
• D. Identify possible solutions

Correct answer: D

Rationale: In resolving ethical dilemmas, it is essential to identify possible solutions to address the client care dilemma effectively. Option A, 'Ensure client autonomy only,' is not comprehensive enough to resolve complex ethical issues. Option B, 'Consider only medical benefits,' overlooks other important factors beyond medical benefits that are involved in ethical decision-making. Option C, 'Ensure clear communication among the health care team,' is important but may not be sufficient on its own to resolve the ethical dilemma. Therefore, the most effective strategy among the given options is to identify possible solutions to navigate through the ethical dilemma.

4. A healthcare professional is collecting data from a client who has hypokalemia. Which of the following findings should the healthcare professional expect?

• A. Muscle stiffness
• B. Bradycardia
• C. Hyperreflexia
• D. Muscle weakness

Correct answer: D

Rationale: The correct answer is 'Muscle weakness.' Hypokalemia is characterized by low potassium levels, which can lead to muscle weakness due to impaired muscle function. Choices A, B, and C are incorrect findings associated with other medical conditions and not typically expected in hypokalemia. Muscle stiffness is more commonly associated with conditions like tetany or muscle cramps, bradycardia is more commonly associated with issues like heart block or hypothyroidism, and hyperreflexia is more commonly seen in conditions like hyperthyroidism or spinal cord injuries.

5. A client with type 2 diabetes mellitus is concerned about weight gain during pregnancy. Which of the following responses should the nurse make?

• A. You should not gain more than 10 lbs
• B. Your weight gain should be the same as for someone without diabetes
• C. Avoid gaining more than 15 lbs
• D. You should gain more weight because of your condition

Correct answer: B

Rationale: The correct answer is B. Clients with type 2 diabetes should aim for the same pregnancy weight gain as those without diabetes. Option A is too restrictive and may not be appropriate for a healthy pregnancy. Option C also imposes a specific limit without considering individual needs. Option D is incorrect as excessive weight gain can lead to complications in pregnancy, especially for individuals with diabetes.

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