Nursing Elites

1. Implementing counseling by the nurse specialist for the raped victim represents:

• A. assessment.
• B. crisis intervention.
• C. empathetic concern.
• D. unwarranted intrusion.

Correct answer: B

Rationale: Choice B, crisis intervention, is the correct answer. Counseling by a nurse specialist in a rape crisis situation is a form of crisis intervention, which is part of the Crisis Intervention Model. It aims to provide immediate support and help the victim cope with the traumatic event. Empathetic concern (Choice C) is important but refers more to the nurse's attitude rather than the specific action described. Assessment (Choice A) typically involves gathering information and may have already been done before counseling. Unwarranted intrusion (Choice D) is not applicable here as the counseling is provided to support the victim in a professional and caring manner.

2. A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period?

• A. Teaching perineal wound care techniques
• B. Monitoring electrolyte levels
• C. Encouraging early ambulation
• D. Facilitating perineal wound drainage

Correct answer: D

Rationale: The priority nursing care during the post-op period for a client who underwent an abdominal perineal resection is to facilitate perineal wound drainage. This is crucial for preventing infection of the surgical site and promoting healing. Teaching perineal wound care techniques, as in choice A, is more appropriate than ileostomy care in this scenario. While monitoring electrolyte levels is important, it is not the priority compared to ensuring proper wound drainage, making choice B less crucial. Encouraging early ambulation, as in choice C, is beneficial but not as critical as facilitating wound drainage immediately post-op.

3. A woman seeks assistance because she recently remembered childhood sexual abuse. The nurse should include which of the following goals for this client?

• A. prosecuting the perpetrator
• B. managing symptoms of anxiety and fear
• C. determining if the memories are real
• D. collaborating with the client's story

Correct answer: B

Rationale: The correct answer is 'managing symptoms of anxiety and fear.' When a client remembers childhood sexual abuse, the nurse's primary goal should be to help the client cope with the emotional distress and symptoms such as anxiety and fear. Prosecuting the perpetrator is not within the nurse's scope of practice and is a legal matter. Determining if the memories are real is not the nurse's role; the focus should be on providing support and care. Collaborating with the client's story is vague and does not address the immediate emotional needs of the client.

4. Which of the following factors can impact an individual's ability to give informed consent?

• A. IQ
• B. educational level
• C. pain medications
• D. financial status

Correct answer: C

Rationale: Pain medications might alter alertness, thought processes, and reactions, potentially impacting an individual's ability to give informed consent. It is recommended to approach a client for consent at least 4 hours after the last dose of pain medicine to minimize any influence. Choices A, B, and D are incorrect. While IQ and educational level may affect how information is presented during the discussion process, they do not directly impact informed-consent decision-making. Financial status is also not a direct factor in an individual's ability to provide informed consent, unlike pain medications which can directly affect cognitive functions and decision-making abilities.

5. A man expresses surprise that his wife has become very withdrawn during hospitalization for pneumonia. Which response helps the husband understand how some people cope with hospitalization?

• A. "Hospitalization might cause a crisis. Has your wife had to cope with problems before this?"?
• B. "Some people react that way. She will be more talkative when she feels better."?
• C. "Your wife might be feeling concern that she cannot fulfill her normal roles."?
• D. "This is typical behavior for someone who is as ill as your wife."?

Correct answer: A

Rationale: The correct response acknowledges that hospitalization can lead to a crisis for both patients and their families. By asking if the wife has coped with problems before, it opens up a dialogue about her coping mechanisms and past experiences. This can help the husband understand his wife's current behavior better and provide valuable insights. Choices B, C, and D do not directly address the potential crisis that hospitalization can cause or inquire about the wife's coping strategies, making them less effective responses.

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