Nursing Elites

1. Which entry in the client record best reflects significant data on a male client who is admitted with complaints of chest pain?

• A. Nurse will check client q1h for the presence of chest pain
• B. Client has a nervous, tense personality and is likely to overreact
• C. Client states he will notify the nurse if chest pain returns
• D. Client understands how to use the call button and the telephone

Correct answer: C

Rationale: The correct answer is C because documenting the client's statement about notifying the nurse if chest pain returns provides direct, relevant information about their condition. This entry indicates the client's awareness of their symptoms and their willingness to seek assistance, which is crucial in managing chest pain. Choice A is incorrect because it focuses on the nurse's actions rather than the client's condition. Choice B is irrelevant as it discusses the client's personality rather than their current health issue. Choice D, though related to communication, does not directly address the client's chest pain complaint.

2. In developing a plan of care for a client admitted to a mental health unit after attempting suicide by taking a handful of medications, which goal has the highest priority?

• A. Signs a no-self-harm contract
• B. Sleep for at least 6 hours nightly
• C. Attends group therapy every day
• D. Verbalizes a positive self-image

Correct answer: A

Rationale: The correct answer is A: Signs a no-self-harm contract. Ensuring the client’s immediate safety by having them commit to not engaging in self-harm is the highest priority after a suicide attempt. This measure aims to prevent further harm to the client. While sleep, group therapy, and self-image are important aspects of care, they are secondary to ensuring the client's safety in the immediate aftermath of a suicide attempt. Prioritizing the establishment of a no-self-harm contract creates a foundation for addressing other therapeutic goals in the client's care plan.

3. When assessing a client with acute asthma, the nurse is most likely to obtain which finding?

• A. Pursed lip breathing and clubbing of fingers
• B. Fever and a high-pitched inspiratory stridor
• C. A short expiratory phase and hemoptysis
• D. Cough and musical breath sounds on expiration

Correct answer: D

Rationale: When assessing a client with acute asthma, a cough and wheezing or musical breath sounds on expiration are typical findings. Pursed lip breathing and clubbing of fingers (choice A) are not common in acute asthma but could be seen in chronic respiratory conditions. Fever and high-pitched inspiratory stridor (choice B) are more indicative of croup or epiglottitis. A short expiratory phase and hemoptysis (choice C) are not typical findings in acute asthma.

4. The client who is to avoid any weight-bearing on the left leg is using a 3-point crutch gait for ambulation. What is the best action for the nurse to initiate?

• A. Encourage continued use of the 3-point crutch gait by the client
• B. Encourage the client to use a wheelchair for mobility
• C. Instruct the client in the use of a 4-point crutch gait
• D. Instruct the client in the use of a 2-point crutch gait

Correct answer: C

Rationale: In this scenario, the client needs to avoid weight-bearing on the left leg. A 4-point crutch gait involves using both crutches and both legs, making it more appropriate for weight-bearing restrictions. Encouraging the use of a 3-point gait (choice A) would not provide adequate support for the client's condition. While using a wheelchair (choice B) could be an option, instructing the client in a 4-point crutch gait would promote mobility while adhering to weight-bearing restrictions. A 2-point crutch gait (choice D) involves using both crutches and one leg, which is not suitable for avoiding weight-bearing on the left leg.

5. A female client on the mental health unit frequently asks the nurse when she can be discharged. Then, becoming more anxious, she begins to pace the hallway. What intervention should the nurse implement first?

• A. Review the current treatment plan with the client
• B. Inform the healthcare provider about the client’s behaviors
• C. Determine if the client has PRN medication for anxiety
• D. Explore the client’s reasons for wanting to be discharged

Correct answer: D

Rationale: Exploring the client’s reasons for wanting to be discharged should be the first intervention as it helps to address underlying anxieties and concerns. By understanding the client's motivations, the nurse can provide appropriate support and interventions. It can also reduce distress and improve the therapeutic relationship. Reviewing the treatment plan (Choice A) may be important but addressing the immediate distress takes precedence. Informing the healthcare provider (Choice B) can be considered later if necessary. Determining if the client has PRN medication (Choice C) is relevant, but exploring the underlying reasons for the desire to be discharged is more beneficial in this situation.

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