Nursing Elites

1. The nurse observes bilateral bruises on the arms of an elderly client in a long-term care facility. Which of the following questions should the nurse ask this client?

• A. "How did you get those bruises?"?
• B. "Did someone grab you by your arms?"?
• C. "Do you fall often?"?
• D. "What did you bump against?"?

Correct answer: B

Rationale: The correct answer is asking, "Did someone grab you by your arms?"? This question is direct and addresses the possibility of abuse, which is crucial when dealing with suspected abuse cases. It is important to ask direct questions in a sensitive and non-accusatory manner to gather information. Choice A is too general and may not prompt a disclosure of abuse. Choice C assumes falling as the cause without addressing abuse directly. Choice D is vague and does not specifically inquire about potential abuse, making it less effective in identifying abuse cases compared to the correct choice.

2. James returns home from school angry and upset because his teacher gave him a low grade on an assignment. After returning home from school, he kicks the dog. This coping mechanism is known as:

• A. denial
• B. suppression
• C. displacement
• D. fantasy

Correct answer: C

Rationale: The correct answer is 'displacement.' Displacement is a defense mechanism where emotions or impulses are transferred from their original source to a substitute target. In this scenario, James is displacing his anger from his teacher onto the dog. Choice A, 'denial,' involves refusing to acknowledge an unpleasant reality. Choice B, 'suppression,' is the conscious effort to push unwanted thoughts out of awareness. Choice D, 'fantasy,' refers to imagining scenarios that fulfill one's desires but are not based in reality.

3. The LPN is teaching a first-time mother about breastfeeding her newborn. Which statement, if made by the mother, would reflect that the teaching had been successful?

• A. "My baby should be having at least 4-6 wet diapers a day until 1 month."?
• B. "It's nice that breastfed babies eat a bit less than formula-fed babies."?
• C. "My baby should be nursing 8-12 times a day during this period."?
• D. "I'm a little nervous about my milk coming in tomorrow. I've heard it's uncomfortable."?

Correct answer: C

Rationale: The correct answer is, '"My baby should be nursing 8-12 times a day during this period."?' This statement indicates successful teaching because newborns should nurse 8-12 times during the newborn period to ensure they receive adequate nutrition and establish a good milk supply. This frequency helps in meeting the baby's demands for growth and development. Choice A is incorrect because while it mentions the appropriate number of wet diapers a day once the mother's milk comes in, it does not reflect successful teaching about breastfeeding frequency. Choice B is incorrect because it discusses feeding amounts in comparison to formula-fed babies, which is not a direct indicator of successful breastfeeding teaching. Choice D is incorrect because it focuses on the mother's concerns about milk coming in, not on understanding the feeding frequency needed for the newborn.

4. Ashley and her boyfriend Chris, both 19 years old, are transported to the Emergency Department after being involved in a motorcycle accident. Chris is badly hurt, but Ashley has no apparent injuries, though she appears confused and has trouble focusing on what is going on around her. She complains of dizziness and nausea. Her pulse is rapid, and she is hyperventilating. The nurse should assess Ashley's level of anxiety as:

• A. mild.
• B. moderate.
• C. severe.
• D. panic.

Correct answer: C

Rationale: Explanation: Ashley is displaying symptoms of severe anxiety, including confusion, trouble focusing, dizziness, nausea, rapid pulse, and hyperventilation. These somatic symptoms, along with changes in vital signs, indicate severe anxiety. In severe anxiety, individuals are unable to solve problems and have a poor grasp of their environment. On the other hand, mild anxiety may lead to mild discomfort or even enhanced performance, while moderate anxiety results in difficulty grasping information and minor changes in vital signs. Panic, the most severe level of anxiety, involves markedly disturbed behavior and a potential loss of touch with reality. Therefore, based on Ashley's symptoms, her anxiety level should be assessed as severe.

5. Tricyclics (Antidepressants) can sometimes have which of the following adverse effects on patients diagnosed with depression?

• A. Shortness of breath
• B. Fainting
• C. Large intestine ulcers
• D. Distal muscular weakness

Correct answer: B

Rationale: The correct answer is 'Fainting.' Tricyclic antidepressants can cause fainting and hypotension as adverse effects. Shortness of breath (Choice A) is not a common side effect of tricyclics. Large intestine ulcers (Choice C) are not typically associated with tricyclic antidepressants. Distal muscular weakness (Choice D) is not a common adverse effect of tricyclics but is commonly associated with other medications.

Similar Questions