Nursing Elites

1. The nurse is preparing an older client for discharge. Which method is best for the nurse to use when evaluating the client's ability to perform a dressing change at home?

• A. Determine how well the client can change the dressing.
• B. Ask the client to demonstrate the procedure.
• C. Seek a family member's opinion on the client's dressing change ability.
• D. Observe the client change the dressing unassisted.

Correct answer: D

Rationale: The best method for the nurse to evaluate the client's ability to perform a dressing change at home is by observing the client change the dressing unassisted. Direct observation allows the nurse to assess if the client has mastered the skill and provides an opportunity to confirm the proficiency. Options A, B, and C do not offer the same level of assessment as direct observation. Option A incorrectly focuses on the client's feelings rather than their actual performance ability. Option B, asking the client to demonstrate the procedure, may not accurately reflect their practical skills. Option C, seeking a family member's opinion, introduces potential bias and may not provide an accurate assessment of the client's ability to perform the dressing change independently.

2. What is a priority goal of involuntary hospitalization of the severely mentally ill client?

• A. Re-orientation to reality
• B. Elimination of symptoms
• C. Protection from harm to self or others
• D. Return to independent functioning

Correct answer: C

Rationale: The priority goal of involuntary hospitalization of severely mentally ill clients is to ensure protection from harm to self or others. Involuntary hospitalization is often necessary for individuals who are deemed dangerous to themselves or others or who are considered gravely disabled. Re-orientation to reality, elimination of symptoms, and return to independent functioning are important aspects of mental health care but are not the primary goals of involuntary hospitalization. The main focus during involuntary hospitalization is to address safety concerns and prevent harm.

3. During a scheduled health maintenance visit, which common source of stress for a 6-year-old client would the nurse include in the teaching session?

• A. Wanting to be first
• B. Demanding privacy
• C. Having a desire to be like an idol
• D. Being more selective with playmates

Correct answer: A

Rationale: A common source of stress for a 6-year-old school-age client is competition, such as wanting to be first or the best (winning). This aspect can create stress for a 6-year-old as they navigate social interactions and activities. Therefore, the nurse would address this issue during the teaching session at the health maintenance visit. Demanding privacy, having a desire to be like an idol, and being more selective with playmates are characteristics more commonly associated with 7-year-old clients, not typically seen in the stressors of a 6-year-old. Understanding age-appropriate stressors is crucial for providing tailored education and support in pediatric care.

4. A 19-year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of "suppression"?

• A. "I don't remember anything about what happened to me."
• B. "I'd rather not talk about it right now."
• C. "It's the other guy's fault! He was going too fast."
• D. "My mother is heartbroken about this."

Correct answer: A

Rationale: The correct answer is "I don't remember anything about what happened to me." This statement indicates the use of suppression, which is the willful act of putting an unacceptable thought or feeling out of one's mind. In this case, the client is deliberately excluding memories of the traumatic event to protect their self-esteem. The other choices do not reflect suppression: Choice B shows avoidance or deflection, Choice C demonstrates blame shifting, and Choice D indicates empathy towards another individual.

5. Which response would the nurse make at lunchtime to a client who is sitting alone with the head slightly tilted as if listening to something?

• A. "I know you're busy, but it's lunchtime."
• B. "Are the voices bothering you again?"
• C. "Get going; you don't want to miss lunchtime."
• D. "It's lunchtime; I'll walk with you to the dining room."

Correct answer: D

Rationale: The statement, "It's lunchtime; I'll walk with you to the dining room," demonstrates setting limits and providing support. Hallucinations can be frightening, and the nurse's presence offers support and reality without focusing on the hallucination directly. Choice A, "I know you're busy, but it's lunchtime," does not recognize the client's need for support and direction. Choice B, "Are the voices bothering you again?", makes a judgment without sufficient evidence and overly focuses on the hallucination, failing to address the client's need for support and direction. Choice C, "Get going; you don't want to miss lunchtime," does not acknowledge the client's need for reality, support, and direction, and may come across as threatening.

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