Nursing Elites

1. The child with seizure disorder is being treated with Dilantin (phenytoin). Which of the following statements by the patient's mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy?

• A. "She is very irritable lately."?
• B. "She sleeps quite a bit of the time."?
• C. "Her gums look too big for her teeth."?
• D. "She has gained about 10 pounds in the last 6 months."?

Correct answer: C

Rationale: The correct answer is '"Her gums look too big for her teeth."?' Hyperplasia of the gums is a known side effect associated with Dilantin therapy. Option A, '"She is very irritable lately,"?' is not a typical side effect of Dilantin. Option B, '"She sleeps quite a bit of the time,"?' is a common side effect of Dilantin but not specific to gum hyperplasia. Option D, '"She has gained about 10 pounds in the last 6 months,"?' is not typically associated with Dilantin therapy and is unrelated to the question.

2. A 57-year-old woman is recently widowed. She states, 'I will never be able to learn how to manage the finances. My husband did all of that.' Select the nurse's response that could help raise the client's self-esteem.

• A. "You feel inadequate because you have never learned to balance a checkbook."?
• B. "You should have insisted your husband teach you about the finances."?
• C. "You are strong and will learn how to manage your finances after a while."?
• D. "Why don't you take a class in basic finance from the local college?"?

Correct answer: C

Rationale: The nurse can raise the client's self-esteem by acknowledging the client's feelings and providing positive reinforcement. Choice C shows empathy and support by recognizing the client's strength and potential to learn. This response encourages the client to believe in her abilities and instills confidence. Choices A and B may come across as judgmental or critical, which can further lower the client's self-esteem. Choice D, while offering a solution, does not address the client's emotional needs or provide direct reassurance about her capabilities.

3. Several clients are admitted to the emergency room following a three-car vehicle accident. Which clients can be assigned to share a room in the emergency department during the disaster?

• A. The schizophrenic client experiencing visual and auditory hallucinations and the client with ulcerative colitis
• B. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm
• C. A child with fixed and dilated pupils and his parents, and the client with a frontal head injury
• D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain

Correct answer: B

Rationale: The correct answer is to assign the client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm to share a room. The pregnant client needs close monitoring due to the abdominal pain, and the client with facial lacerations and a broken arm requires immediate attention for wound care and possible fracture management. Choice A should not be assigned together as the schizophrenic client experiencing visual and auditory hallucinations needs a separate room for privacy and safety, and the client with ulcerative colitis may require isolation due to the risk of infection. Choice C is incorrect because the child with fixed and dilated pupils is likely in a critical condition and should be in a private room with parents, while the client with a frontal head injury needs a separate room for focused care. Choice D is also incorrect as the client with a large puncture wound to the abdomen needs immediate attention in a separate room, and the client with chest pain requires evaluation and monitoring in a separate setting as well.

4. A 57-year-old woman is recently widowed. She states, "I will never be able to learn how to manage the finances. My husband did all of that."? Select the nurse's response that could help raise the client's self-esteem.

• A. "You feel inadequate because you have never learned to balance a checkbook."?
• B. "You should have insisted your husband teach you about the finances."?
• C. "You are strong and will learn how to manage your finances after a while."?
• D. "I believe in your strength to learn how to manage your finances in time."?

Correct answer: C

Rationale: The nurse should aim to boost the client's self-esteem by providing positive reinforcement. By stating, "You are strong and will learn how to manage your finances after a while,"? the nurse acknowledges the client's strength and capability, encouraging her to believe in herself. Choice A is incorrect as it focuses on the client's inadequacy rather than empowering her. Choice B places unnecessary blame on the client for not taking action in the past. Choice D, though positive, slightly alters the nurse's original phrase, making choice C the most appropriate response to uplift the client's self-esteem.

5. 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.

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