Nursing Elites

1. When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority?

• A. Impaired comfort.
• B. Risk for injury.
• C. Ineffective breathing pattern.
• D. Ineffective coping.

Correct answer: C

Rationale: Ineffective breathing pattern is the highest priority nursing problem in this scenario because aspiration of a caustic material can lead to serious airway and respiratory issues. This poses an immediate threat to the client's life and requires urgent intervention to ensure adequate oxygenation and ventilation. The other options, such as Impaired comfort, Risk for injury, and Ineffective coping, are important but are secondary concerns compared to the critical nature of respiratory compromise in this situation.

2. A client is admitted for bipolar disorder and alcohol withdrawal, depressive phase. Based on which assessment finding will the RN withhold the clonidine (Catapres) prescription?

• A. Blood pressure readings of 90/62 mmHg to 92/58 mmHg.
• B. Pulse rate of 68-78 BPM.
• C. Temperature of 99.5-99.7°F.
• D. Respiration rate of 24 breaths per minute.

Correct answer: A

Rationale: In this scenario, the correct answer is A. Clonidine, such as Catapres, is a medication that can lower blood pressure. Therefore, if a client has low blood pressure readings, like 90/62 mmHg to 92/58 mmHg, the registered nurse should withhold the clonidine prescription to prevent further lowering of blood pressure which could lead to adverse effects. Choices B, C, and D are incorrect because they are within normal ranges and do not present a contraindication for the administration of clonidine in this context.

3. The client is being educated by the healthcare provider about starting a prescribed abstinence therapy with disulfiram (Antabuse). What information should the client understand?

• A. Maintain complete abstinence from alcohol consumption.
• B. Stay alcohol-free for at least 12 hours before the first dose.
• C. Participate in monthly therapy sessions.
• D. Disclose to others that he is receiving disulfiram therapy.

Correct answer: B

Rationale: The correct answer is B. Before starting disulfiram therapy (Antabuse), the client must comprehend the need to remain alcohol-free for a minimum of 12 hours. This is crucial to prevent the unpleasant and potentially dangerous reactions that can occur with concurrent alcohol consumption while on disulfiram. Choice A is incorrect because it mentions heroin or cocaine use, which is not the primary focus when initiating disulfiram therapy. Choice C is incorrect as it suggests therapy sessions, which are not specifically required before starting disulfiram. Choice D is incorrect as there is no need to disclose disulfiram therapy to others, but rather to adhere to the abstinence requirement.

4. A male client is admitted to the psychiatric inpatient unit with a bandaged flesh wound after attempting to shoot himself. He was divorced one year ago, lost his job four months ago, and suffered a breakup of his current relationship last week. What is the most likely source of this client’s current feelings of depression?

• A. Feelings of frustration.
• B. A sense of loss.
• C. Poor self-esteem.
• D. A lack of intimate relationships.

Correct answer: B

Rationale: The client's recent history of divorce, job loss, and breakup of a current relationship indicates a series of significant losses. These losses are likely the primary source of his feelings of depression, leading to a sense of loss. While feelings of frustration (choice A) and poor self-esteem (choice C) could be contributing factors, the immediate trigger for his current emotional state appears to be the series of losses. A lack of intimate relationships (choice D) may be a consequence of the client's depressive symptoms rather than the root cause in this scenario.

5. A client with anorexia nervosa has a body mass index (BMI) of 16.5 and has been diagnosed with bradycardia. Which of the following findings should the RN be most concerned about?

• A. Body temperature of 96.8°F.
• B. Heart rate of 52 BPM.
• C. Serum potassium level of 4.1 mEq/L.
• D. Electrocardiogram (ECG) changes.

Correct answer: D

Rationale: In a client with anorexia nervosa and bradycardia, monitoring for ECG changes is crucial as these changes may indicate potentially life-threatening cardiac complications. While other findings like low body temperature, bradycardia, and serum potassium levels are concerning, ECG changes specifically reflect the impact of bradycardia on the heart's electrical activity and should be the priority for the nurse to assess and address.

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