Nursing Elites

1. Which of the following is a recommended approach for handling aggressive behavior in a mental health setting?

• A. Encourage the client to express their feelings through physical activity
• B. Avoid making eye contact to prevent escalation
• C. Use pharmacological interventions immediately
• D. Maintain eye contact, offer clear choices, and set boundaries

Correct answer: D

Rationale: The recommended approach for handling aggressive behavior in a mental health setting is to maintain eye contact, offer clear choices, and set boundaries. This approach can help de-escalate the situation by establishing communication and structure. Choice A is incorrect as encouraging physical activity may not be suitable during an aggressive episode. Choice B is incorrect because avoiding eye contact can hinder communication and resolution. Choice C is also incorrect as pharmacological interventions should not be the immediate go-to method for managing aggression unless absolutely necessary.

2. A nurse is presenting educational materials for a group of middle-aged clients about menopausal hormone therapy following a total hysterectomy. Which of the following information should the nurse include?

• A. Take at different times of the day
• B. Prevents from having a cerebral hemorrhage
• C. Prevents osteoporotic fractures
• D. Take an extra dose if missed a day

Correct answer: C

Rationale: The correct information the nurse should include is that menopausal hormone therapy helps prevent osteoporotic fractures by maintaining bone density. Option A is incorrect as hormone therapy should be taken consistently at the same time each day for optimal effectiveness. Option B is incorrect as menopausal hormone therapy is not primarily aimed at preventing cerebral hemorrhage. Option D is incorrect because taking an extra dose is not recommended if a dose is missed; instead, the missed dose should be taken as soon as remembered, unless it is close to the time for the next dose.

3. A nurse witnesses a colleague administering the wrong IV solution to a client. What should the nurse do first?

• A. Complete an incident report.
• B. Ask the colleague if they intend to report the error.
• C. Call the healthcare provider to notify them of the error.
• D. Notify the supervisor about the situation.

Correct answer: B

Rationale: The correct first step for the nurse to take in this situation is to ask the colleague if they intend to report the error. It is important to address the error promptly and directly with the colleague involved to ensure that the appropriate actions are taken to correct the mistake and prevent harm to the client. Completing an incident report, calling the healthcare provider, or notifying the supervisor can be done after discussing the error with the colleague. Immediate communication with the colleague directly involved in the error is crucial to address the situation effectively.

4. The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder. Which priority action will the nurse take?

• A. Assist the patient with comfort measures.
• B. Keep the patient as mobile as possible.
• C. Encourage the patient to perform ROM.
• D. Encourage the patient to do self-care.

Correct answer: A

Rationale: The correct answer is A: 'Assist the patient with comfort measures.' When a patient is experiencing impaired physical mobility due to pain, the priority action is to provide comfort measures to help manage the pain. By addressing the pain, the patient may then feel more comfortable moving and engaging in mobility exercises. Option B, 'Keep the patient as mobile as possible,' could exacerbate the pain and should not be the initial action. While encouraging range of motion (ROM) exercises (Option C) and self-care (Option D) are important aspects of care, addressing pain and comfort should take precedence in this scenario.

5. A nurse in an emergency department is preparing a change-of-shift report for an adult client who is transferring to a medical-surgical unit using the SBAR communication tool. Which of the following information should the nurse include in the report?

• A. The client has a do-not-resuscitate order.
• B. The client has a continuous IV of lactated Ringer's.
• C. The client was straight catheterized for 350 mL 2 hours ago.
• D. The client has Medicare insurance.

Correct answer: A

Rationale: In an SBAR report, key information such as the client's do-not-resuscitate (DNR) status should be included as it directly impacts the client's care and treatment plan. Choices B and C are important details but may not be as critical for immediate care planning during the shift change. Choice D, the client having Medicare insurance, is important for billing purposes but does not directly impact the client's immediate care needs.

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