Nursing Elites

1. A complication of total parenteral nutrition (TPN) is the development of cholestasis. What is this condition?

• A. an inflammatory process of the extrahepatic bile ducts
• B. an arrest of the normal flow of bile
• C. an inflammation of the gallbladder
• D. the formation of gallstones

Correct answer: B

Rationale: Cholestasis due to TPN administration is an intrahepatic process that interrupts the normal flow of bile. It is characterized by a reduction or stoppage of bile flow. Choice A, an inflammatory process of the extrahepatic bile ducts, refers to cholangitis, not cholestasis. Choice C, an inflammation of the gallbladder, describes cholecystitis, a different condition. Choice D, the formation of gallstones, is not correct as cholestasis is about the flow of bile, not the formation of gallstones.

2. The client is diagnosed with multiple myeloma. The doctor has ordered cyclophosphamide (Cytoxan). Which instruction should be given to the client?

• A. "Walk about a mile a day to prevent calcium loss."?
• B. "Increase the fiber in your diet."?
• C. "Report nausea to the doctor immediately."?
• D. "Drink at least eight large glasses of water a day."?

Correct answer: D

Rationale: Cyclophosphamide (Cytoxan) can cause hemorrhagic cystitis, a condition characterized by inflammation of the bladder wall leading to bleeding. To prevent this complication, the client should drink at least eight glasses of water a day. Walking to prevent calcium loss (choice A) and increasing fiber intake (choice B) are not directly related to the side effects of Cytoxan, making them unnecessary instructions in this case. While nausea is a common side effect of chemotherapy, the immediate reporting of nausea to the doctor (choice C) is important but not specifically related to the use of Cytoxan in this scenario.

3. A man reports his wife is constantly cleaning, which interferes with family life. Friends avoid visiting due to feeling uncomfortable. The husband finds her cleaning even at night. The nurse should consult and recommend the husband help with therapy by:

• A. telling his wife to stop cleaning whenever he notices her actions.
• B. making a baseline record of the time the wife spends cleaning.
• C. decreasing the stimuli in the home.
• D. helping his wife with the cleaning.

Correct answer: C

Rationale: The correct answer is to decrease the stimuli in the home. The wife's behavior suggests obsessive-compulsive disorder, an anxiety disorder. By reducing stimuli in the environment, such as clutter or triggers that prompt cleaning, it helps in managing the condition and promoting a calmer atmosphere. Option A is incorrect as directly telling the wife to stop can escalate her anxiety. Option B is not the priority initially, as addressing the root cause is more crucial. Option D may reinforce the behavior rather than addressing the underlying issue.

4. After the client discusses her relationship with her father, the nurse says, "Tell me whether I am understanding your relationship with your father. You feel dominated and controlled by him?"? This is an example of:

• A. verbalizing the implied.
• B. seeking consensual validation.
• C. encouraging evaluation.
• D. suggesting collaboration.

Correct answer: B

Rationale: Seeking consensual validation is the correct answer. Consensual validation is a technique used to check one's understanding of what the client has said. It involves confirming with the client whether the nurse's interpretation aligns with the client's feelings or thoughts. This process helps build rapport, trust, and a shared understanding between the nurse and the client. Verbalizing the implied (choice A) refers to expressing the underlying or implicit meaning of a client's statement. Encouraging evaluation (choice C) involves prompting the client to assess or judge a situation. Suggesting collaboration (choice D) entails proposing working together with the client on a shared goal, which is not the primary focus in the scenario provided.

5. A nurse is teaching the mother of an 11-month-old infant how to clean the infant's teeth. The nurse tells the mother to take which action?

• A. Use a small amount of toothpaste and a soft-bristle toothbrush
• B. Use water and a cotton swab and rub the teeth
• C. Use diluted fluoride and rub the teeth with a soft washcloth
• D. Dip the infant's pacifier in maple syrup so that the infant will suck

Correct answer: C

Rationale: The correct action when cleaning an infant's teeth is to use water and a cotton swab to gently rub the teeth. This method helps in removing any food particles or plaque buildup without the risks associated with toothpaste ingestion. Using a small amount of toothpaste and a soft-bristle toothbrush is not recommended for infants as they may swallow the toothpaste, leading to potential fluoride ingestion issues. Using diluted fluoride and rubbing the teeth with a soft washcloth is unnecessary at this age since infants typically receive fluoride through other sources like formula. Dipping the infant's pacifier in maple syrup is highly inappropriate and poses a significant risk of tooth decay due to the high sugar content, which can harm the infant's teeth.

Similar Questions