Nursing Elites

1. A nurse is caring for a dying client whose family wants to be with him in the operating suite. The surgeon, however, does not allow families to be present during surgery. The nurse recognizes this as an ethical dilemma. What is the initial step of the nurse when managing this situation?

• A. Contact the physician to amend the order for the client
• B. Document an account of the situation to ensure adequate coverage of details
• C. Consult with the medical ethics committee to determine a safe and workable solution
• D. Speak with the chief nursing officer to change the policy governing this situation

Correct answer: A

Rationale: In this type of situation, the first action of the nurse should be to address the immediate needs of the client by requesting the physician to make a change based on the circumstances. The primary concern is to ensure the client's well-being and honor the family's wishes, even if it means deviating from standard protocols. While documentation (Choice B) and consulting with higher authorities like the medical ethics committee (Choice C) may be necessary at a later stage, the initial step is to take action to meet the client's needs promptly. Speaking with the chief nursing officer to change the policy (Choice D) is not the most immediate or practical step in this situation, as the focus should be on the client's current care needs.

2. Jaime has a diagnosis of schizophrenia with negative symptoms. In planning care for the client, Nurse Brienne would anticipate a problem with:

• A. Auditory hallucinations
• B. Bizarre behaviors
• C. Ideas of reference
• D. Motivation for activities

Correct answer: D

Rationale: In clients with negative symptoms of schizophrenia, such as Jaime, a common problem is avolition, which is the lack of motivation for activities. These 'negative' symptoms are characterized by inexpressive faces, blank looks, monotone speech, few gestures, and a seeming lack of interest in the world. Patients may also experience an inability to feel pleasure or act spontaneously. It is crucial to differentiate between the lack of expression and lack of feeling, as well as between lack of will and lack of activity. Auditory hallucinations (choice A) are positive symptoms, not typically associated with negative symptoms of schizophrenia. Bizarre behaviors (choice B) are more aligned with positive symptoms like disorganized behavior. Ideas of reference (choice C) involve incorrectly interpreting casual incidents and external events as having direct reference to oneself, which is not directly related to motivation for activities seen in negative symptoms.

3. You are taking care of Mary Eden, an elderly and frail 91-year-old resident. She gets confused during evening hours and at times she thinks that she hears her daughter calling her from the other side of the nursing home. Which physical problem places Mary Eden at risk for falls?

• A. Her confusion
• B. Her daughter
• C. Evening hours
• D. Her frailness

Correct answer: D

Rationale: Mary Eden's frail and weak muscles due to her age and physical condition place her at risk for falls. While her confusion can contribute to falls, it is considered an emotional or cognitive issue rather than a physical problem. Her daughter and the evening hours are not physical problems that directly increase her risk of falling.

4. While caring for a client in labor, a nurse attaches an electronic fetal monitor to the client's abdomen to assess the baby's heart rate. The nurse observes that the baby's heart rate slows down during each contraction and does not return to normal limits until after the contraction is complete. What type of fetal heart rate change does this pattern describe?

• A. Variable decelerations
• B. Late decelerations
• C. Early decelerations
• D. Accelerations

Correct answer: B

Rationale: Late decelerations are characterized by the baby's heart rate declining in utero during contractions. The heart rate drops below baseline and stays low until after the contraction ends. Late decelerations are concerning as they indicate uteroplacental insufficiency, which can compromise fetal oxygenation. This pattern is a non-reassuring sign and requires immediate intervention. Variable decelerations are typically abrupt decreases in heart rate, often associated with cord compression. Early decelerations, on the other hand, mirror the contractions and are considered benign, resulting from fetal head compression. Accelerations are reassuring signs of fetal well-being, indicating a responsive and healthy fetal nervous system.

5. Which of these devices is considered a protective device, rather than a restraint?

• A. A mitten on the hands to prevent scratching
• B. A mitten on the hands to prevent the person from pulling their IV out
• C. A side rail to prevent the patient from falling
• D. A soft wrist restraint to prevent the patient from pulling their IV tubing

Correct answer: A

Rationale: A mitten on the hands to prevent scratching is considered a protective device because its primary purpose is to protect the patient from harming themselves by scratching. It does not restrict the patient's movement. Choice B, a mitten on the hands to prevent the person from pulling their IV out, is considered a restraint as it limits the patient's movement. Choice C, a side rail to prevent the patient from falling, is also a protective device as it aims to keep the patient safe by providing support and preventing falls. Choice D, a soft wrist restraint to prevent the patient from pulling their IV tubing, is a type of restraint as it restricts the patient's movement to prevent them from interfering with medical equipment.

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