Nursing Elites

1. A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, 'I want to go outside now and smoke. It takes forever to get anything done here!' Which intervention is best for the nurse to implement?

• A. Encourage the client to use a nicotine patch.
• B. Reassure the client that it is almost time for another break.
• C. Have the client leave the unit with another staff member.
• D. Review the schedule of outdoor breaks with the client.

Correct answer: D

Rationale: The best nursing action is to review the schedule of outdoor breaks and provide concrete information about the schedule. Suggesting a nicotine patch (Option A) is not suitable as the client wants to smoke. Reassuring the client about another break (Option B) does not address the client's frustration and does not promote effective communication. Having the client leave the unit with another staff member (Option C) is not appropriate as it goes against unit rules and does not address the client's concerns. Therefore, the most appropriate intervention is to review the schedule of outdoor breaks with the client to provide clarity and address the client's frustration effectively.

2. Which nursing intervention helps foster the development of a trusting parent-child relationship?

• A. Placing the infant in a crib with a mobile or soft toy
• B. Discouraging eye contact when the infant is irritable
• C. Putting objects several inches in front of the infant for viewing
• D. Encouraging face-to-face contact between the parents and infant

Correct answer: D

Rationale: Encouraging face-to-face contact between parents and infants is crucial in fostering a trusting parent-child relationship. Eye-to-eye contact promotes interaction and bonding, helping the infant develop trust in their caregivers. Placing the infant in a crib with a mobile or soft toy may provide stimulation but does not directly contribute to the emotional bonding necessary for trust. Discouraging eye contact when the infant is irritable can hinder communication and connection. Putting objects in front of the infant for viewing is beneficial for visual stimulation but does not actively promote the emotional attachment and trust that face-to-face contact does.

3. An adolescent client comes to the clinic 3 weeks after the birth of her first baby. She tells the nurse she is concerned because she has not returned to her pre-pregnant weight. Which action should the nurse perform first?

• A. Review the client's weight pattern over the year
• B. Ask the mother to record her diet for the last 24 hours
• C. Encourage her to talk about her view of herself
• D. Give her several pamphlets on postpartum nutrition

Correct answer: C

Rationale: Encouraging the adolescent client to talk about her view of herself is the first action the nurse should take. Body image is crucial for adolescents, especially after pregnancy. By addressing the client's concerns about her weight and discussing her self-perception, the nurse can provide emotional support and open a dialogue for further assessment and teaching. Choice A, 'Review the client's weight pattern over the year,' is not the priority at this time as the client's immediate concern is her post-pregnancy weight. Choice B, 'Ask the mother to record her diet for the last 24 hours,' focuses on dietary habits rather than addressing the client's emotional concerns. Choice D, 'Give her several pamphlets on postpartum nutrition,' may be helpful but should come after addressing the client's emotional needs and concerns.

4. During a scheduled health maintenance visit, which common source of stress for a 6-year-old client would the nurse include in the teaching session?

• A. Wanting to be first
• B. Demanding privacy
• C. Having a desire to be like an idol
• D. Being more selective with playmates

Correct answer: A

Rationale: A common source of stress for a 6-year-old school-age client is competition, such as wanting to be first or the best (winning). This aspect can create stress for a 6-year-old as they navigate social interactions and activities. Therefore, the nurse would address this issue during the teaching session at the health maintenance visit. Demanding privacy, having a desire to be like an idol, and being more selective with playmates are characteristics more commonly associated with 7-year-old clients, not typically seen in the stressors of a 6-year-old. Understanding age-appropriate stressors is crucial for providing tailored education and support in pediatric care.

5. Which response would the nurse make at lunchtime to a client who is sitting alone with the head slightly tilted as if listening to something?

• A. "I know you're busy, but it's lunchtime."
• B. "Are the voices bothering you again?"
• C. "Get going; you don't want to miss lunchtime."
• D. "It's lunchtime; I'll walk with you to the dining room."

Correct answer: D

Rationale: The statement, "It's lunchtime; I'll walk with you to the dining room," demonstrates setting limits and providing support. Hallucinations can be frightening, and the nurse's presence offers support and reality without focusing on the hallucination directly. Choice A, "I know you're busy, but it's lunchtime," does not recognize the client's need for support and direction. Choice B, "Are the voices bothering you again?", makes a judgment without sufficient evidence and overly focuses on the hallucination, failing to address the client's need for support and direction. Choice C, "Get going; you don't want to miss lunchtime," does not acknowledge the client's need for reality, support, and direction, and may come across as threatening.

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