Nursing Elites

1. The client with partial-thickness (second-degree) and full-thickness (third-degree) burns is at risk of infection. What intervention has the highest priority in decreasing the client's risk of infection?

• A. Administration of plasma expanders
• B. Use of careful handwashing technique
• C. Application of a topical antibacterial cream
• D. Limiting visitors to the client with burns

Correct answer: B

Rationale: The correct answer is the use of careful handwashing technique. Proper handwashing is the most effective way to prevent the transmission of infectious organisms. Option A, administration of plasma expanders, addresses hypovolemia in burn patients but does not directly decrease the risk of infection. Option C, application of a topical antibacterial cream, is beneficial but not as effective as proper handwashing in preventing infection. Option D, limiting visitors, may help reduce the risk of exposure to pathogens but is not as critical as ensuring healthcare providers maintain strict hand hygiene, which is the cornerstone of infection control in any healthcare setting.

2. What nonverbal action should the nurse implement to demonstrate active listening?

• A. Sit facing the client.
• B. Cross arms and legs.
• C. Avoid eye contact.
• D. Lean back in the chair.

Correct answer: A

Rationale: Active listening is effectively demonstrated through attentive verbal and nonverbal communication strategies. To convey active listening and show the client that the nurse is engaged and attentive, it is essential for the nurse to sit facing the client. This posture communicates openness and willingness to listen. Option B, crossing arms and legs, creates a barrier and can signal defensiveness or disinterest, making it an incorrect choice. Option C, avoiding eye contact, hinders the establishment of a connection and can convey disengagement. Option D, leaning back in the chair, may give the impression of disinterest or lack of engagement. Therefore, maintaining eye contact and sitting facing the client are crucial nonverbal actions to exhibit active listening and promote effective therapeutic communication.

3. When assisting a client from the bed to a chair, which procedure is best for the nurse to follow?

• A. Place the chair parallel to the bed, with its back toward the head of the bed, and assist the client in moving to the chair.
• B. With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair.
• C. Assist the client to a standing position by gently lifting upward from underneath the axillae.
• D. Stand beside the client, place the client's arms around the nurse's neck, and gently move the client to the chair.

Correct answer: B

Rationale: Option B is the correct procedure for assisting a client from the bed to a chair. By positioning the nurse's feet apart and aligning the knees with the client's knees, the nurse maintains a stable base of support while pivoting the client into the chair. This technique minimizes the risk of injury to both the nurse and the client. Placing the chair at a 45-degree angle to the bed, with the back of the chair toward the head of the bed, provides a clear path for the client to move. Option C is incorrect because lifting a client under the axillae can potentially cause nerve damage and strain. Option D is also incorrect as it involves an unsafe method of moving the client and can lead to injuries or accidents.

4. Which parameter would be assessed to determine the degree of anxiety being experienced by the client?

• A. Memory state
• B. Creativity level
• C. Perceptual field
• D. Delusional system

Correct answer: C

Rationale: The correct parameter to assess the degree of anxiety experienced by a client is the perceptual field. As anxiety increases, perceptual fields tend to narrow. Memory state, creativity level, and delusional system are not directly related to the level of anxiety and are not appropriate parameters for determining the degree of anxiety. Memory state refers to the ability to remember, creativity level to the ability to generate new ideas or solutions, and delusional system to a set of false beliefs.

5. Which therapeutic technique can the nurse use when an anxious client exhibits pressured and rambling speech?

• A. Touch
• B. Silence
• C. Focusing
• D. Summarizing

Correct answer: C

Rationale: Focusing is the appropriate therapeutic technique to use when an anxious client exhibits pressured and rambling speech. By focusing on one specific aspect, the intended meaning is easier to understand and helps the client stay on track. Touch is not recommended in this scenario as it can invade the client's personal space and potentially increase anxiety. Silence may allow the client to continue rambling without addressing the underlying concerns. Summarizing requires the identification and exploration of the client's concerns, which may be challenging when the speech is pressured and disorganized.

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