Nursing Elites

1. What should be done to minimize the risk of injury for a client with dementia?

• A. Ensure the client has consistent caregivers
• B. Dim the lights in the client's room
• C. Allow the client to sleep with the bedrails raised
• D. Encourage family members to stay with the client

Correct answer: A

Rationale: The correct answer is to ensure the client has consistent caregivers. This helps reduce confusion and stress for clients with dementia by providing familiarity and routine. Dimming the lights in the client's room (Choice B) may not directly address the risk of injury. Allowing the client to sleep with the bedrails raised (Choice C) can pose a risk if not properly monitored. Encouraging family members to stay with the client (Choice D) may not always be feasible and may not provide the necessary professional support and consistency that consistent caregivers can offer.

2. A client with dementia is at risk of falls. Which intervention should the nurse implement to ensure safety?

• A. Use restraints to prevent the client from leaving the bed
• B. Use a bed exit alarm to notify staff when the client tries to leave the bed
• C. Encourage frequent ambulation with assistance
• D. Raise all four side rails to prevent falls

Correct answer: B

Rationale: The correct intervention for a client with dementia at risk of falls is to use a bed exit alarm to notify staff when the client tries to leave the bed. This intervention helps prevent falls while still allowing some freedom of movement. Choice A is incorrect because using restraints can lead to complications and is considered a form of restraint which should be avoided. Choice C is not suitable for a client at high risk of falls due to dementia as it may increase the risk of falls. Choice D is not recommended as raising all four side rails can be considered a form of physical restraint and may not be the best approach to prevent falls in a client with dementia.

3. A nurse is collecting data from a client who is experiencing a situational crisis following the loss of a job. The client states, 'I don't think I can go through this again.' Which of the following actions is the nurse's priority?

• A. Determine if the client is experiencing psychotic thinking
• B. Determine the client's support system
• C. Ask how the client copes with stress
• D. Assess the client's vital signs

Correct answer: A

Rationale: The priority is to determine if the client is experiencing psychotic thinking or suicidal ideation. In this situation, the nurse needs to assess if the client is having distorted thoughts or losing touch with reality, which could pose an immediate risk to the client's safety. While determining the client's support system, asking how the client copes with stress, and assessing vital signs are important aspects of care, they are not the priority when there is a concern about potential psychotic thinking or suicidal ideation.

4. A client with active tuberculosis is receiving discharge instructions. Which statement by the client indicates an understanding of the teaching?

• A. I will continue taking my isoniazid until I am no longer contagious.
• B. I should take my prescribed medication for at least 6 months.
• C. I will need to have a TB skin test every 3 months.
• D. I should wear a mask at all times.

Correct answer: B

Rationale: The correct answer is B because the client should take antitubercular medications for a minimum of 6 months to ensure complete eradication of the infection. Choice A is incorrect as stopping the medication early can result in treatment failure and development of drug-resistant TB. Choice C is incorrect as regular TB skin tests are not needed once the client has been diagnosed and treated. Choice D is incorrect as wearing a mask at all times is not necessary for a client with active TB; proper cough etiquette should be followed instead.

5. A nurse has administered medications to a group of clients. For which of the following client situations should the nurse complete an incident report?

• A. Administering acetaminophen to an NPO client
• B. Administering insulin lispro to an NPO client
• C. Administering medication to the incorrect client
• D. Administering anticoagulants without checking INR

Correct answer: B

Rationale: The correct answer is B because administering insulin lispro to an NPO client can lead to hypoglycemia due to the lack of food to balance the medication. This situation poses a serious risk to the client's safety and should be documented in an incident report. Choice A is not as critical as insulin administration for an NPO client. Choice C is also serious but does not pose an immediate risk to the client's health. Choice D, administering anticoagulants without checking the INR, is important but does not require an incident report unless adverse effects occur, as it may not immediately endanger the client's life.

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