Nursing Elites

1. A client in a long-term care facility reports to the nurse that he has not had a bowel movement in 2 days. Which intervention should the nurse implement first?

• A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes.
• B. Notify the healthcare provider and request a prescription for a large-volume enema.
• C. Assess the client's medical record to determine the client's normal bowel pattern.
• D. Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day.

Correct answer: C

Rationale: The first step in addressing a client's reported change in bowel habits is to assess the client's normal bowel pattern. This assessment helps the nurse understand the client's typical bowel habits and identify any deviations from the norm. By assessing the medical record first, the nurse gains valuable information that guides further interventions. In this scenario, offering prune juice (Option A) or increasing fluids (Option D) may not be appropriate until the client's normal bowel pattern is known. Notifying the healthcare provider for a large-volume enema (Option B) is premature without understanding the client's baseline. Therefore, assessing the client's medical record is the priority before proceeding with any interventions.

2. A 20-year-old young adult has been recently admitted to the hospital. According to Erikson, which of the following stages is the adult in?

• A. Trust vs. mistrust
• B. Initiative vs. guilt
• C. Autonomy vs. shame
• D. Intimacy vs. isolation

Correct answer: D

Rationale: The young adult, at 20 years old, is in the stage of Intimacy vs. Isolation according to Erikson's psychosocial theory. This stage typically occurs during young adulthood, between the ages of approximately 19 and 40. The primary conflict in this stage revolves around the development of intimate, loving relationships with others. This stage focuses on establishing close bonds and connections with others, seeking emotional closeness and commitment. Choices A, B, and C are incorrect. Trust vs. mistrust is the stage that occurs in infancy, Initiative vs. guilt is in early childhood, and Autonomy vs. shame is in toddlerhood. These stages each represent different developmental challenges and conflicts that individuals face at various points in their lives.

3. A client who has been on hemodialysis for 2 years communicates in an angry, critical manner and does not adhere to the prescribed medications and diet. Which explanation for the client's behavior would be useful to consider in planning care?

• A. An attempt to punish the nursing staff
• B. A constructive method of accepting reality
• C. A defense against underlying depression and fear
• D. An effort to maintain life and to live it as fully as possible

Correct answer: C

Rationale: The client's angry, critical communication and non-adherence to treatment suggest underlying emotional struggles. The behavior is likely a defense mechanism against feelings of depression and fear. It is essential to consider that the client's actions are not intentionally aimed at punishing others but rather a manifestation of internal distress. Option A is incorrect as the behavior is not about punishing the nursing staff. Option B is incorrect because the behavior is not a constructive way of accepting reality but rather a maladaptive coping mechanism. Option D is incorrect as the behavior is not primarily driven by an effort to maintain life but rather by emotional distress.

4. The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the nurse do next?

• A. Apply a warm compress proximal to the site.
• B. Check for kinks in the tubing and raise the IV pole.
• C. Adjust the tape that stabilizes the needle.
• D. Flush with normal saline and recount the drop rate.

Correct answer: B

Rationale: When encountering a slowed peripheral IV rate, the nurse should initially check for common factors affecting infusion rates. Factors such as the height of the IV bag, presence of kinks in the tubing, needle size or position, client blood pressure, fluid viscosity, and infiltration can impact the rate. It is crucial to ensure the tubing is free of any kinks and that the IV pole is at an appropriate height to facilitate proper flow by gravity. Applying warmth proximal to the site might help with venospasm, but this intervention should come after ensuring proper tubing flow. Adjusting the tape that stabilizes the needle or flushing with normal saline may be necessary later in the troubleshooting process, but these actions should follow checking for kinks and adjusting the IV pole height, which are less invasive interventions.

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.

Similar Questions