Nursing Elites

1. Which nursing action is best when managing a client with severe anxiety?

• A. Maintain a calm manner
• B. Help the client identify thoughts prior to the anxiety
• C. Administer anti-anxiety medication
• D. Initiate seclusion if anxiety escalates

Correct answer: A

Rationale: The correct answer is to maintain a calm manner. When managing a client with severe anxiety, the nurse's calm presence can help the client feel more secure and reduce their anxiety levels. It is essential to create a safe and supportive environment. Helping the client identify thoughts prior to anxiety (choice B) may be beneficial in cognitive-behavioral interventions but may not be the initial best action for severe anxiety. Administering anti-anxiety medication (choice C) should be done by a healthcare provider's order and is not the first-line intervention for managing severe anxiety. Initiating seclusion (choice D) should only be considered as a last resort if the client is at risk of harm to themselves or others, as it can further escalate anxiety and should not be the initial action.

2. A community health nurse is helping to reinforce teaching about hepatitis A with a group of employees at a childcare facility. Which of the following characteristics should the nurse identify as an external factor that can impede learning for the participants?

• A. High workload
• B. Limited knowledge on the subject
• C. Poor lighting
• D. Limited space in the learning area

Correct answer: C

Rationale: The correct answer is C: 'Poor lighting.' External factors such as lighting can significantly impact the learning environment, making it difficult for participants to engage effectively. Poor lighting can strain the eyes, cause discomfort, and lead to decreased concentration. Choices A, B, and D are internal factors or issues that are not directly related to the learning environment. High workload, limited knowledge on the subject, and limited space in the learning area may affect learning differently but do not impede learning through external factors like poor lighting does.

3. A nurse is reviewing the plan of care for a client undergoing radiation therapy for cancer. Which of the following instructions should the nurse reinforce with the client?

• A. Apply sunscreen before going outside
• B. Avoid using perfumed lotions
• C. Massage the area daily
• D. Take vitamin supplements with food

Correct answer: B

Rationale: The correct instruction the nurse should reinforce with the client undergoing radiation therapy is to avoid using perfumed lotions. This is essential to reduce the risk of skin irritation, as perfumed lotions can exacerbate skin reactions during radiation therapy. Applying sunscreen before going outside is generally a good practice but not specifically related to radiation therapy. Massaging the area daily is contraindicated during radiation therapy as it can further irritate the skin. Taking vitamin supplements with food is important for overall health but is not a specific instruction related to radiation therapy.

4. How should a healthcare provider assess a patient with potential diabetic ketoacidosis (DKA)?

• A. Monitor blood glucose and check for ketones in urine
• B. Administer insulin and provide fluids
• C. Administer potassium and check for electrolyte imbalance
• D. Administer sodium bicarbonate and monitor urine output

Correct answer: A

Rationale: Correct answer: To assess a patient with potential diabetic ketoacidosis (DKA), healthcare providers should monitor blood glucose and check for ketones in the urine. Elevated blood glucose levels and the presence of ketones in urine are indicative of DKA. Choice B is incorrect because administering insulin and providing fluids are treatments for DKA rather than assessment measures. Choice C is incorrect as administering potassium and checking for electrolyte imbalance are interventions related to managing DKA complications, not initial assessment. Choice D is incorrect because administering sodium bicarbonate and monitoring urine output are not primary assessment actions for DKA.

5. What are key signs of fluid overload?

• A. Edema
• B. Hypertension
• C. Shortness of breath
• D. All of the above

Correct answer: D

Rationale: The correct answer is 'D: All of the above.' Edema, hypertension, and shortness of breath are key signs of fluid overload, particularly common in patients with heart failure. Edema refers to the swelling caused by excess fluid trapped in the body's tissues, hypertension can be a result of fluid volume overload, and shortness of breath can occur due to fluid accumulation in the lungs. Therefore, all these signs collectively indicate fluid overload in a patient. Choices A, B, and C are incorrect individually as each alone may not necessarily indicate fluid overload, but when seen together, they strongly suggest fluid volume excess in the body.

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