Nursing Elites

1. After informing an older client that an IV line needs to be inserted, the client becomes very apprehensive, loudly verbalizing a dislike for all healthcare providers and nurses. How should the nurse respond?

• A. Ask the client to remain quiet so the procedure can be performed safely.
• B. Concentrate on completing the insertion as efficiently as possible.
• C. Calmly reassure the client that the discomfort will be temporary.
• D. Tell the client a joke as a means of distraction from the procedure.

Correct answer: C

Rationale: The nurse should respond with a calm demeanor to help reduce the client's apprehension. By calmly reassuring the client that the discomfort from the procedure will be temporary, the nurse acknowledges the client's feelings and provides comfort. This response shows empathy and understanding, which can help build trust. Asking the client to remain quiet may escalate the situation and not address the client's underlying concerns. Concentrating solely on completing the insertion efficiently may overlook the client's emotional needs and may increase their anxiety. Telling a joke may not be appropriate in this serious situation and could be perceived as insensitive, failing to address the client's emotional distress effectively.

2. When observing an infant lying quietly in the bassinet with eyes open wide, what action should the nurse take in response to the infant's behavior?

• A. Brightening the lights in the room
• B. Encouraging the mother to talk to her baby
• C. Wrapping and then turning the infant to the side
• D. Beginning physical and behavioral assessments

Correct answer: B

Rationale: When an infant is lying quietly in a bassinet with eyes open wide, it indicates a quiet, alert state. This state is optimal for infant stimulation and interaction. Bright lights can be disturbing to newborns and may disrupt the mother-infant interaction. Wrapping and turning the infant to the side is typically done for a sleeping infant. While physical and behavioral assessments are important, in this scenario, the priority is to encourage mother-infant bonding and communication, as it is a valuable opportunity for interaction and stimulation.

3. While conducting an intake assessment of an adult male at a community mental health clinic, the nurse notes that his affect is flat, he responds to questions with short answers, and he reports problems with sleeping. He reports that his life partner recently died from pneumonia. Which action is most important for the nurse to implement?

• A. Encourage the client to see the clinic's grief counselor.
• B. Determine if the client has a family history of suicide attempts.
• C. Inquire about whether the life partner was suffering from AIDS.
• D. Consult with the health care provider about the client's need for antidepressant medications.

Correct answer: A

Rationale: The client is exhibiting normal grieving behaviors, so referral to a grief counselor is the most important intervention for the nurse to implement. Option B is relevant but is not a high-priority intervention compared to addressing the immediate grief support needs of the client. Option C is irrelevant at this time but might be important when determining the client's risk for contracting the illness. While antidepressant medication might be necessary based on further assessment, grief counseling is a more appropriate initial action as grief is a typical response to the loss of a loved one.

4. A neonate born at 32 weeks' gestation and weighing 3 lb (1361 g) is admitted to the neonatal intensive care unit (NICU). When would the nurse take the neonate's mother to visit the infant?

• A. When the infant's condition has stabilized
• B. When the infant is out of immediate danger
• C. When the primary health care provider has provided written permission
• D. When the mother is well enough to be taken to the NICU

Correct answer: D

Rationale: The mother should see her infant as soon as possible to acknowledge the reality of the birth and begin bonding. Delaying the visit may impede maternal-infant bonding. The timing of the mother's visit should be based on her physical and emotional readiness, not solely on the infant's condition or the need for written permission. The nurse can independently facilitate the mother's visit without requiring a prescription from the primary healthcare provider.

5. One week after being told that she has terminal cancer with a life expectancy of 3 weeks, a female client tells the nurse, 'I think I will plan a big party for all my friends.' How should the nurse respond?

• A. 'You may not have enough energy before long to hold a big party.'
• B. 'Do you mean to say that you want to plan your funeral and wake?'
• C. 'Planning a party and thinking about all your friends sounds like fun.'
• D. 'You should be thinking about spending your last days with your family.'

Correct answer: C

Rationale: Setting goals that bring pleasure is appropriate and should be encouraged by the nurse as long as the nurse does not perpetuate a client's denial. Option A is a negative response, implying that the client should not plan a party, which is not supportive. Option B is presumptive and may not reflect the client's true intentions. The correct response (Option C) acknowledges the client's positive plans and encourages her to enjoy her time with friends. Option D, while family is important, does not consider the client's wishes and choices, which should be respected and supported in this situation.

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