Nursing Elites

1. The discharge planning team is discussing plans for the dismissal of a 16-year-old admitted for complications associated with asthma. The client's mother has not participated in any of the discharge planning processes but has stated that she wants to be involved. Which of the following reasons might prohibit this mother from participating in discharge planning?

• A. The client is an emancipated minor
• B. The mother has to work and is unavailable
• C. The client has a job and a driver's license
• D. The mother does not speak English

Correct answer: A

Rationale: In this scenario, the correct answer is that the client is an emancipated minor. Emancipated minors, even if they are under the age of 18, have the legal right to make decisions about their own healthcare and planning, which may include not wanting their parent involved in the discharge planning process. This status grants them independence from parental involvement in certain situations. The other choices are incorrect because the mother's work schedule, the client's job and possession of a driver's license, and the mother's language proficiency do not inherently prevent her from participating in the discharge planning process, unlike the legal status of being an emancipated minor.

2. Mr. K is admitted to the orthopedic unit one morning in preparation for a total knee replacement to start in two hours. Which of the following is a priority topic to instruct this client on admission?

• A. The approximate length of the surgery
• B. The type of anticoagulants that will be prescribed
• C. The time of the next meal of solid food
• D. The length of time until the client can return to work

Correct answer: A

Rationale: The priority topic to instruct a client admitted for a total knee replacement surgery should be the approximate length of the surgery. Pre-surgical teaching should focus on preparing the client for the upcoming procedure. Providing information about the duration of the surgery can help manage the client's expectations, reduce anxiety, and ensure they are mentally prepared for the operation. While details about post-operative care, anticoagulants, meals, and return to work are important, they are not the immediate priority during the preoperative phase. These aspects can be addressed at a later stage in the client's care journey.

3. A nurse is caring for an in-patient client in the hospital who is from another country and who fasts for temporary periods in order to promote his own spiritual growth. The nurse responds by saying, 'You need to eat something while you are here. Food and proper nutrition are extremely important for your health.' What social philosophy is the nurse demonstrating?

• A. Ethnocentrism
• B. Relativism
• C. Stereotyping
• D. Xenocentrism

Correct answer: A

Rationale: The nurse's response reflects ethnocentrism, a belief that one's own cultural practices are superior to others. Ethnocentrism involves viewing one's own culture as the standard by which all others should be judged. In this scenario, the nurse's insistence that the client needs to eat disregards the client's cultural and spiritual beliefs, considering only the nurse's perspective as valid. B: Relativism is the recognition and acceptance of cultural differences without judgment. The nurse's behavior does not align with relativism as there is a lack of understanding and acceptance of the client's cultural practices. C: Stereotyping involves making assumptions about individuals based on predefined characteristics. While the nurse may have made assumptions, the core issue in this scenario is the belief in the superiority of one's own cultural practices. D: Xenocentrism is the opposite of ethnocentrism, where one perceives other cultures as superior to their own. The nurse's actions are not driven by a belief in the superiority of the client's culture but rather by a belief in the superiority of her own cultural practices.

4. Which of the following is an example of the intervention phase of the individualized nursing care plan for a client who receives a colostomy after a bowel resection?

• A. Taking a health history and performing a physical exam prior to the procedure
• B. Instructing the client about how to care for his colostomy stoma
• C. Developing goals that state the client will ambulate three times a day
• D. Determining that the client may need more support at home after dismissal

Correct answer: B

Rationale: The intervention stage of the individualized nursing care plan is where the nurse provides care, treatments, or education to help the client meet the devised outcomes. Instructing the client about how to care for his colostomy stoma is the correct example of an intervention as it directly involves providing education and guidance to the client on post-operative care. This intervention supports the process of helping the client meet the outcomes designed for this case, which is to enable the client to properly care for his colostomy after a bowel resection. The other options do not directly involve interventions aimed at assisting the client in meeting the specific care needs related to the colostomy procedure.

5. Which of the following tasks may be delegated to unlicensed assistive personnel?

• A. Cleansing a wound with peroxide
• B. Irrigating a colostomy
• C. Assisting with performing incentive spirometry
• D. Removing a saline-lock IV

Correct answer: C

Rationale: Certain tasks can be safely delegated to unlicensed assistive personnel to assist nurses in their workload. Tasks that involve routine activities like incentive spirometry can be delegated. Unlicensed assistive personnel can assist clients with incentive spirometry, helping in promoting lung expansion and preventing respiratory complications. Cleansing a wound with peroxide (Choice A) and irrigating a colostomy (Choice B) involve more complex procedures that should be performed by licensed healthcare providers due to the risk of infection and potential complications. Removing a saline-lock IV (Choice D) requires specialized training and should only be performed by licensed personnel to prevent complications and ensure patient safety. The nurse remains responsible for delegating tasks appropriately and overseeing the care provided by unlicensed assistive personnel.

Similar Questions