Nursing Elites

1. The nurse is caring for a client who is dying. While assessing the client for signs of impending death, the nurse observes the client for:

• A. elevated blood pressure.
• B. Cheyne-Stokes respiration.
• C. elevated pulse rate.
• D. decreased temperature.

Correct answer: B

Rationale: Cheyne-Stokes respirations are a pattern of breathing characterized by rhythmic waxing and waning of respirations from very deep to very shallow breathing with periods of temporary apnea. This pattern is often associated with conditions like cardiac failure and can be a sign of impending death. Elevated blood pressure and pulse rate are not typically associated with the dying process. Decreased temperature is also not a common sign of impending death. Therefore, option B, Cheyne-Stokes respiration, is the correct choice when assessing a client for signs of impending death.

2. The nurse is developing a care plan for a client with severe anxiety. An appropriate outcome for the client is that within 4 days the client should:

• A. Have decreased anxiety.
• B. Talk to the nurse for 10 minutes.
• C. Sit quietly for 30 minutes.
• D. Develop an adaptive coping mechanism.

Correct answer: B

Rationale: When developing outcome criteria for a client with severe anxiety, it is crucial for the goals to be specific, measurable, and realistic. In this scenario, the most appropriate outcome is for the client to talk to the nurse for 10 minutes within 4 days. This goal is specific (talking for a defined duration), measurable (10 minutes), and realistic given the client's condition. Expecting a severely anxious client to sit quietly for 30 minutes is not realistic and may even exacerbate their anxiety. While developing an adaptive coping mechanism is important, it is a broader long-term goal and may not be achievable within the specified timeframe. Having decreased anxiety is a desirable outcome, but it lacks specificity and measurability, making it less suitable as an immediate goal.

3. Using clich�s in therapeutic communication leads the client to:

• A. viewing the nurse as less understanding.
• B. accepting themselves as human.
• C. self-disclosing.
• D. feeling discounted.

Correct answer: D

Rationale: The use of clich�s in therapeutic communication is commonly construed by the client as the nurse's lack of understanding, involvement, and caring, which can lead the client to feel demeaned and discounted. Choice A is incorrect because clich�s do not make the client view the nurse as less understanding but rather as lacking depth in communication. Choice B is incorrect as clich�s do not directly lead the client to accepting themselves as human. Choice C is incorrect because clich�s usually hinder self-disclosure rather than encourage it.

4. A client is taking hydrocodone (Vicodin) for chronic back pain. The client has required an increase in the dose and asks whether this means he is addicted to Vicodin. The nurse should base her reply on the knowledge that:

• A. the client's body has developed tolerance, requiring more drug to produce the same effect.
• B. the client is preoccupied with getting the drug and is experiencing loss of control, indicating drug dependence.
• C. addiction is the term used to describe physical dependence with withdrawal symptoms and tolerance.
• D. the client has a dual diagnosis of substance abuse and chronic back pain

Correct answer: A

Rationale: Drug tolerance is characterized by the ability to ingest a larger dose without adverse effects and decreased sensitivity to the substance. In this scenario, the client needing an increased dose of hydrocodone to achieve the same pain relief indicates tolerance developing, not addiction. Choice B is incorrect as it describes drug dependence, where the individual is preoccupied with the drug and has a loss of control. Choice C is incorrect because addiction involves psychological behaviors related to substance use, not just physical dependence with withdrawal symptoms and tolerance. Choice D is incorrect as it refers to a dual diagnosis, which is the coexistence of substance abuse and psychiatric disorders, not the development of tolerance to a drug.

5. When helping a client gain insight into anxiety, the nurse should:

• A. help the client relate anxiety to specific triggers.
• B. ask the client to describe events that precede increased anxiety.
• C. encourage the client to practice relaxation techniques.
• D. address the client's resistive behavior.

Correct answer: B

Rationale: When assisting a client in gaining insight into anxiety, it is crucial to explore the events that lead to increased anxiety. By asking the client to describe these events, the nurse can help the client recognize patterns and triggers, leading to a better understanding of their anxiety. Option A is incorrect because it refers to triggers rather than exploring the events leading to anxiety. Option C is incorrect as it focuses on relaxation techniques rather than delving into the root causes of anxiety. Option D is inappropriate as addressing resistive behavior may not foster a supportive therapeutic environment for the client.

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