Nursing Elites

1. The nurse selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the nurse use to identify the placement of the IV access?

• A. Left brachial vein
• B. Right cephalic vein
• C. Dorsal side of the right wrist
• D. Right upper extremity

Correct answer: B

Rationale: The correct answer is the right cephalic vein. The cephalic vein is a large and superficial vein commonly used for IV access. Documenting the specific anatomic name of the vein used for IV access, such as the cephalic vein, is essential for accurate medical records. Option A, the left brachial vein, is incorrect as the brachial vein is too deep to be accessed for IV infusion. Option C, the dorsal side of the right wrist, is not a recommended IV access site due to fragile veins and potential pain for the patient. Option D, right upper extremity, is too broad and lacks the specificity necessary for precise documentation of the IV access site.

2. While reviewing the side effects of a newly prescribed medication, a 72-year-old client notes that one of the side effects is a reduction in sexual drive. Which is the best response by the nurse?

• A. How will this affect your present sexual activity?
• B. How active is your current sex life?
• C. How has your sex life changed as you have become older?
• D. Tell me about your sexual needs as an older adult.

Correct answer: A

Rationale: The best response in this scenario is option A, 'How will this affect your present sexual activity?' This response directly addresses the client's concern and allows them to express their thoughts and feelings. Option B does not directly address the client's worry about the medication's side effect. Options C and D deviate from the client's immediate concern and are not as relevant in this situation.

3. 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.

4. When a man with dementia is admitted to a long-term care facility, his wife, who appears tired and angry, says in a sarcastic tone, 'Let's see what you can do with him.' Which response is therapeutic?

• A. It sounds like it's been difficult for you.'
• B. I don't understand what you mean.'
• C. 'I have experience with all types of clients.'
• D. It's too bad you didn't admit him sooner.'

Correct answer: A

Rationale: The correct response is to acknowledge the caregiver's feelings and challenges without blaming them. Option A, 'It sounds like it's been difficult for you,' shows empathy and opens the channel of communication. Options B and C, 'I don't understand what you mean' and 'I have experience with all types of clients,' are nurse-focused responses that block effective communication. Option D, 'It's too bad you didn't admit him sooner,' is a hostile response that shifts the blame to the caregiver, which is not therapeutic in this situation.

5. Which characteristic usually results in a behavior being viewed and accepted as normal?

• A. Fits within standards accepted by one's society
• B. Helps the person reduce the need for coping skills
• C. Allows the person to express feelings and thoughts
• D. Facilitates achievement of short-term and long-term goals

Correct answer: A

Rationale: Behaviors that align with the standards accepted by a society are generally viewed as normal. Societal norms and values play a significant role in defining what is considered normal behavior. Choices B, C, and D may be important aspects of an individual's functioning, but they do not solely determine whether a behavior is viewed as normal. Coping skills, expressions of feelings, and goal achievement can vary in their cultural context and societal acceptance, therefore they are not definitive indicators of normalcy.

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