Nursing Elites

1. A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is important for the nurse to provide?

• A. Decrease intake of fluids after the evening meal.
• B. Drink a glass of cranberry juice every day.
• C. Drink a glass of warm decaffeinated beverage at bedtime.
• D. Consult the healthcare provider about a sleeping pill.

Correct answer: A

Rationale: Nocturia is characterized by urination during the night, disrupting sleep patterns. Instructing the client to decrease intake of fluids after the evening meal (Option A) can help reduce the production of urine, thereby decreasing the need to void at night. Cranberry juice (Option B) is beneficial for preventing bladder infections but does not address the issue of nocturia. While warm decaffeinated beverages (Option C) may promote sleep, consuming fluids close to bedtime can exacerbate nocturia. Consulting the healthcare provider about a sleeping pill (Option D) is not the first-line intervention and may lead to urinary incontinence if the client is sedated and unable to awaken to void, worsening the nocturia issue.

2. A client injured in a motor vehicle accident was brought to the emergency department and taken immediately for a scan. The client's family arrives and asks about the client's condition. Which response would the nurse provide?

• A. Please do not worry; everything will be all right.
• B. I am sorry; I do not have any information about the client.
• C. You will have to wait for the primary health care provider.
• D. Please wait; I will update you as soon as I have any information.

Correct answer: D

Rationale: In this situation, the most appropriate response for the nurse to provide to the client's family is to assure them that they will be updated as soon as there is relevant information available. This response not only acknowledges the family's concern but also demonstrates the nurse's commitment to keeping them informed. Option A, providing false reassurances, is not advisable as it may impact the family's ability to cope with potential bad news. Option B, stating that the nurse has no information, is not helpful and can cause distress. Option C, directing the family to the primary health care provider, is not ideal as the nurse should strive to communicate directly with the family to establish trust and provide support.

3. During a routine assessment, an obese 50-year-old female client expresses concern about her sexual relationship with her husband. Which is the best response by the nurse?

• A. Reassure the client that many obese individuals have concerns about sex.
• B. Remind the client that sexual relationships can remain unaffected by obesity.
• C. Determine the frequency of sexual intercourse.
• D. Ask the client to talk about specific concerns.

Correct answer: D

Rationale: Option D is the best response as it allows the client to express her specific concerns, providing the nurse with valuable assessment data. This open-ended question encourages the client to share her worries and feelings, which can guide the nurse in addressing her unique needs. Options A and B make assumptions about the client's concerns based on her weight, potentially invalidating her feelings and inhibiting effective communication. Option C is premature as understanding the client's concerns should precede discussions about the frequency of sexual intercourse, which may not address the core issues the client is facing.

4. A patient with major depression who has lost 20 pounds in one month, has chronic low self-esteem, and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention is most directly related to this outcome: 'Patient will refrain from gestures and attempts to harm self'?

• A. Implement suicide precautions.
• B. Frequently offer high-calorie snacks and fluids.
• C. Assist the patient to identify three personal strengths.
• D. Observe patient for therapeutic effects of antidepressant medication.

Correct answer: A

Rationale: Implementing suicide precautions is the most critical intervention in this scenario as it directly addresses the patient's safety and the prevention of self-harm. The patient's significant weight loss, chronic low self-esteem, suicide plan, and recent initiation of an antidepressant medication indicate a high risk of self-harm. Suicide precautions involve close monitoring, removing harmful objects, and ensuring a safe environment to prevent the patient from acting on suicidal thoughts. While offering high-calorie snacks and fluids, assisting the patient in identifying personal strengths, and observing for therapeutic effects of the antidepressant are important aspects of care, they do not directly address the immediate risk of self-harm that implementing suicide precautions does.

5. The wife of a client who is dying says, 'I want to see him, but I can only come twice a week because of work, household chores, and caring for our cat and dog.' Which defense mechanism is the wife using?

• A. Projection
• B. Sublimation
• C. Compensation
• D. Rationalization

Correct answer: D

Rationale: The wife is using rationalization as a defense mechanism. Rationalization involves offering a socially acceptable or logical explanation to justify an unacceptable feeling or behavior. In this scenario, the wife justifies her limited visits to her dying husband by citing other responsibilities such as work, household chores, and pet care. Projection involves denying one's unacceptable feelings and attributing them to others. Sublimation is the substitution of unacceptable feelings or drives with socially acceptable behaviors. Compensation involves making up for a perceived deficiency by emphasizing another perceived asset.

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