Nursing Elites

1. Client self-determination is the primary focus of:

• A. malpractice insurance
• B. nursing's advocacy for clients
• C. confidentiality
• D. health care

Correct answer: B

Rationale: Client self-determination refers to the right of clients to make their own decisions about their health care. Nursing's advocacy for clients focuses on upholding this right by supporting and respecting the autonomy and self-determination of clients. This advocacy ensures that clients are empowered to participate in decision-making regarding their health. Confidentiality, while essential, is about maintaining the privacy of client information. Malpractice insurance is a protective measure for professionals in case of errors or negligence. Health care, though crucial for enabling client self-determination, is a broad term encompassing various services and not the primary focus when discussing the client's right to autonomy.

2. The nurse is caring for a client with a malignancy. The classification of the primary tumor is Tis. The nurse should plan care for a tumor:

• A. That can be assessed
• B. That is in situ
• C. With increasing lymph node involvement
• D. With distant metastasis

Correct answer: B

Rationale: The correct answer is B: 'That is in situ.' Cancer in situ means that the cancer is still localized to the primary site. Cancer is graded in terms of tumor, grade, node involvement, and metastasis. Answer A is incorrect because Tis indicates a tumor that is in situ and can be assessed. Answer C is incorrect because T indicates tumor, not node involvement. Answer D is incorrect because a tumor that is in situ is not metastasized.

3. A client with pancreatitis has been transferred to the intensive care unit. Which order would the nurse anticipate?

• A. Blood pressure monitoring every 15 minutes
• B. Insertion of a Levine tube
• C. Continuous cardiac monitoring
• D. Administration of pain medication every 4 hours

Correct answer: B

Rationale: In a client with pancreatitis who frequently experiences nausea and vomiting, insertion of a Levine tube is often anticipated to decompress the stomach and rest the bowel, helping to alleviate symptoms. This intervention is crucial in managing the gastrointestinal symptoms associated with pancreatitis. Blood pressure monitoring every 15 minutes may be necessary in some cases, but it is not a routine order for pancreatitis, making option A less likely. Continuous cardiac monitoring could be required based on the individual's condition, but it is not typically the first priority in pancreatitis management, so option C is not the most anticipated order. While pain medication administration is essential for managing discomfort, the priority in this scenario, especially considering the symptoms of nausea and vomiting, would be decompression with a Levine tube to address gastrointestinal issues, making option D less likely.

4. A client has been taking alprazolam (Xanax) for four years to manage anxiety. The client reports taking 0.5 mg four times a day. Which statement indicates that the client understands the nurse's teaching about discontinuing the medication?

• A. "I can drink alcohol now that I am decreasing my Xanax."?
• B. "I should not take another Xanax pill. Here is what is left of my last prescription."?
• C. "I should take three pills per day next week, then two pills for one week, then one pill for one week."?
• D. "I can expect to be sleepy for several days after stopping the medicine."?

Correct answer: C

Rationale: Explanation: When discontinuing alprazolam (Xanax) after long-term use, it is crucial to taper the dosage gradually to prevent withdrawal symptoms. The correct statement indicates an understanding of this by planning a structured decrease in dosage over time. Choice A is incorrect as drinking alcohol while decreasing Xanax can be dangerous and is not recommended. Choice B is incorrect as abruptly stopping Xanax is not safe and can lead to withdrawal symptoms. Choice D is incorrect as expecting to be sleepy for several days after stopping the medication does not address the need for a gradual tapering process to avoid withdrawal symptoms.

5. A two-year-old has been in the hospital for 3 weeks and has seldom seen family members due to isolation precautions. Which of the following hospitalization changes is most likely to be occurring?

• A. Guilt
• B. Trust
• C. Separation anxiety
• D. Shame

Correct answer: C

Rationale: The correct answer is 'Separation anxiety.' Separation anxiety is a common response in young children when they are separated from their primary caregivers for extended periods. In this case, the two-year-old being in the hospital for three weeks and not being able to see family members due to isolation precautions can trigger separation anxiety. 'Guilt' is a feeling of responsibility for wrongdoing, which is not the most likely change occurring in this scenario. 'Trust' involves reliance and confidence in others, not typically associated with prolonged separation from family. 'Shame' is a negative emotion related to feeling disgrace, which is not the most appropriate response in this hospitalization situation.

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