Nursing Elites

1. Which intervention should be prioritized for a client experiencing panic-level anxiety?

• A. Postpone health teaching until anxiety subsides
• B. Encourage participation in group therapy
• C. Monitor vital signs every 5 minutes
• D. Provide reassurance and remain with the client

Correct answer: D

Rationale: During panic-level anxiety, the priority is to provide reassurance and remain with the client. This intervention helps to offer immediate support, comfort, and a sense of safety to the client. Postponing health teaching until anxiety subsides (Choice A) is not appropriate as the client's immediate emotional needs are more critical. Encouraging participation in group therapy (Choice B) may be beneficial in the long term but is not the priority during a panic attack. While monitoring vital signs (Choice C) is important, providing reassurance and support take precedence in managing panic-level anxiety.

2. A patient is experiencing shortness of breath. What is the nurse's immediate action?

• A. Assist the patient into a high Fowler's position.
• B. Administer oxygen at 2 liters per minute via nasal cannula.
• C. Encourage the patient to take deep breaths and cough.
• D. Assess the patient's lung sounds.

Correct answer: B

Rationale: Administering oxygen at 2 liters per minute via nasal cannula is the immediate action for a patient experiencing shortness of breath. This intervention helps to improve oxygenation and relieve respiratory distress promptly. Placing the patient in a high Fowler's position (choice A) may also be beneficial but providing oxygen takes precedence in this scenario to address the underlying hypoxemia. Encouraging deep breaths and coughing (choice C) may not be appropriate as the first action, especially without assessing the patient first. Assessing lung sounds (choice D) is essential but should follow the initial intervention of administering oxygen.

3. A nurse observes a colleague ignoring proper hand hygiene protocols. What should the nurse do first?

• A. Speak to the colleague directly.
• B. Ignore the situation, as it doesn't involve direct patient care.
• C. Report the colleague to the nursing manager.
• D. File an incident report immediately.

Correct answer: D

Rationale: The correct first action for the nurse to take in this situation is to file an incident report immediately. By doing so, the nurse ensures that the unsafe practice is documented for further investigation and corrective action. Speaking to the colleague directly may not address the root cause of the issue and could lead to potential conflicts. Ignoring the situation is not an appropriate response as it compromises patient safety. Reporting the colleague to the nursing manager should be done after filing an incident report to ensure that appropriate actions are taken to prevent future occurrences of non-compliance with hand hygiene protocols.

4. A forensic nurse is using the epidemiological triangle to explain factors that contribute to violent behavior. Which of the following factors should the nurse identify as an environmental factor in the epidemiological triangle?

• A. Crowded living conditions
• B. Traumatic brain injury
• C. Alzheimer's disease
• D. Impaired coping abilities

Correct answer: A

Rationale: Crowded living conditions are considered an environmental factor in the epidemiological triangle as they can contribute to the spread of violence. In this context, environmental factors refer to external influences such as social and physical environments. Traumatic brain injury, Alzheimer's disease, and impaired coping abilities are not typically classified as environmental factors in the epidemiological triangle. Traumatic brain injury and Alzheimer's disease are more related to individual health conditions, while impaired coping abilities are more focused on individual psychological factors rather than external environmental influences.

5. The patient has been in bed for several days and needs to be ambulated. What action should the nurse take first?

• A. Dangle the patient at the bedside.
• B. Encourage isometric exercises.
• C. Suggest a high-calcium diet.
• D. Maintain a narrow base of support.

Correct answer: A

Rationale: The correct answer is A: 'Dangle the patient at the bedside.' When a patient has been in bed for an extended period and needs to be ambulated, it is essential to dangle the patient at the bedside first. Dangling involves helping the patient sit on the edge of the bed with their legs over the side before standing up. This action helps prevent orthostatic hypotension, a sudden drop in blood pressure when moving from lying down to standing up, which can lead to dizziness or fainting. Encouraging isometric exercises (choice B) or suggesting a high-calcium diet (choice C) are not the first actions to take before ambulating a patient. Maintaining a narrow base of support (choice D) is related to assisting with ambulation but is not the initial step that should be taken.

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