Nursing Elites

1. While obtaining a lie-sit-stand blood pressure reading on a client, what action is most important for the nurse to implement?

• A. Stay with the client while the client is standing.
• B. Record the findings on the graphic sheet in the chart.
• C. Keep the blood pressure cuff on the same arm.
• D. Record changes in the client's pulse rate.

Correct answer: A

Rationale: The most crucial action for the nurse to implement when obtaining a lie-sit-stand blood pressure reading is to stay with the client while the client is standing. This is essential to monitor the client's immediate response to position changes and ensure their safety. Recording the findings on the graphic sheet is important for documentation but is not as critical as staying with the client. Keeping the blood pressure cuff on the same arm helps maintain consistency in readings but is not as vital as ensuring client safety. Recording changes in the client's pulse rate is important for a comprehensive assessment but does not take precedence over monitoring the client during position changes.

2. After a mastectomy or a hysterectomy, a client may feel incomplete as a woman. Which statement would alert the nurse to this feeling in a client who has undergone a total hysterectomy?

• A. "I don't know who can help me during my recovery."
• B. "I feel washed out; there isn't much left."
• C. "I'm scared about the pain in recovery."
• D. "I can't wait to get home; I so want to see my grandchild."

Correct answer: B

Rationale: The correct answer is "I feel washed out; there isn't much left." This statement suggests a feeling of emptiness or incompleteness after the surgical procedure. Concern about who can assist during recovery, fear of pain, or excitement to go home and see a grandchild are not indicative of feeling incomplete as a woman after a hysterectomy. These other statements focus on practical concerns, physical discomfort, and positive emotions, respectively.

3. A Hispanic patient complains of abdominal cramping caused by empacho. Which action should the nurse take first?

• A. Ask the patient what treatments are likely to help
• B. Massage the patient's abdomen until the pain subsides.
• C. Administer prescribed medications to decrease the cramping
• D. Offer to contact a curandero(a) for a visit to the patient

Correct answer: A

Rationale: When a Hispanic patient presents with abdominal cramping related to empacho, it is crucial for the nurse to first understand the patient's cultural beliefs and preferences before initiating any interventions. In the case of a culture-bound syndrome like empacho, it is essential to acknowledge and respect the patient's cultural background. While options like administering medications, arranging a visit by a curandero(a), or providing massage may have potential benefits, assessing the patient's beliefs ensures that interventions are culturally sensitive and aligned with the patient's values. By engaging the patient in a discussion about potential treatments, the nurse can gather valuable information to tailor care effectively, promoting trust and collaboration in the healthcare process. This patient-centered approach enhances the quality of care and fosters a culturally competent nursing practice. Therefore, asking the patient about preferred treatments is the most appropriate initial action to address the patient's condition effectively.

4. The nurse is assessing a young client who presents with recurrent gastrointestinal disorders. On further assessment, the nurse learns that the client is experiencing job-related pressures. Which is the most important nursing intervention for this client?

• A. Educate the client on managing stress.
• B. Teach the client to maintain a balanced diet.
• C. Instruct the client to have regular health checkups.
• D. Ask the client to use sunscreen when working outdoors.

Correct answer: A

Rationale: The most important nursing intervention for a client experiencing job-related pressures and recurrent gastrointestinal disorders is to educate the client on managing stress. Stress is a lifestyle risk factor that can impact both mental health and physical well-being. It is associated with various illnesses, including gastrointestinal disorders. Teaching the client to maintain a balanced diet is important for preventive care and health promotion but is not the priority in this scenario. While instructing the client to have regular health checkups is essential for overall health maintenance, addressing the root cause of stress is crucial in this case. Asking the client to use sunscreen when working outdoors is important for sun protection and skin cancer prevention but not directly related to the client's job-related stress and gastrointestinal issues.

5. Which implemented strategies would not be effective in preventing post-traumatic stress in the nursing staff?

• A. Providing breaks to the staff whenever needed
• B. Encouraging the staff to work for more than 12 hours per day
• C. Encouraging the staff to encourage and support their coworkers
• D. Asking the staff and managers to talk about their feelings with each other

Correct answer: B

Rationale: To prevent post-traumatic stress in the nursing staff, it is crucial to avoid overworking them. Encouraging staff to work for more than 12 hours per day can lead to burnout and increased stress levels, thus exacerbating post-traumatic stress. Providing breaks whenever needed is essential to ensure rest and rejuvenation during demanding shifts. Encouraging staff to support and uplift their coworkers can create a positive work environment, fostering resilience against stress. Additionally, promoting open communication by asking staff and managers to discuss their feelings can facilitate emotional processing and mutual support, ultimately reducing the risk of post-traumatic stress.

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