Nursing Elites

1. Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis?

• A. Perform cough and deep breathing exercises hourly.
• B. Turn from side to side in bed at least every 2 hours.
• C. Dorsiflex and plantarflex the feet 10 times each hour
• D. Drink approximately 4 ounces of water every hour

Correct answer: C

Rationale: To reduce the risk of venous thrombosis, the nurse should instruct the client to perform dorsiflexion and plantar flexion exercises regularly. These exercises help promote venous return and prevent venous thrombus formation. Options A, B, and D are beneficial in managing other complications of immobility, such as atelectasis and pressure ulcers, but they are less effective in preventing venous thrombosis compared to dorsiflexion and plantar flexion exercises.

2. In the care of a withdrawn, reclusive psychotic client, which goal is the priority?

• A. Establish trust
• B. Increase feelings of self-worth
• C. Solidify sense of identity
• D. Improve ability to socialize

Correct answer: A

Rationale: The priority goal in the care of a withdrawn, reclusive psychotic client is to establish trust. Trust is fundamental in building a therapeutic relationship, which is essential for effective care. Without trust, the client may not engage in therapy or interventions. Once trust is established, the nurse can then assess the client's feelings of self-worth, sense of identity, and ability to socialize. While these other goals are important in the overall care of the client, establishing trust forms the foundation for further progress in the therapeutic relationship and treatment.

3. Which of the following is a true statement about palliative care?

• A. The goal of palliative care is to provide end-of-life care for a client as they transition toward death.
• B. Palliative care provides comfort and support for those who may have a terminal illness.
• C. Palliative care provides resources for funeral arrangements after death.
• D. Palliative care is a support network for family and friends after the death of a loved one.

Correct answer: B

Rationale: Palliative care is a type of care that focuses on providing support and comfort to individuals who may have a terminal illness or severe symptoms. It aims to improve the quality of life for both the individual receiving care and their family. While it can be provided in various settings, including hospitals, homes, or specialized facilities, the primary focus is on symptom management and addressing the physical, emotional, and spiritual needs of the individual. Choice A is incorrect because palliative care is not solely limited to end-of-life care but also includes managing symptoms and improving quality of life. Choice C is incorrect as palliative care is focused on providing care and support during the individual's life, not on funeral arrangements after death. Choice D is incorrect as palliative care is primarily directed towards the individual receiving care, although it may also provide support to their family and friends during the care process.

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 entire 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."?' Suppression involves willfully putting an unacceptable thought or feeling out of one's mind. In this case, the client is purposely choosing not to remember details of the traumatic event to avoid dealing with the associated emotions. Choice B, '"I'd rather not talk about it right now,"?' suggests avoidance or deflection rather than active suppression. Choice C, '"It's the other entire guy's fault! He was going too fast,"?' indicates blaming someone else for the situation, which is a form of defense mechanism known as externalization. Choice D, '"My mother is heartbroken about this,"?' expresses empathy towards the mother's emotions and does not demonstrate suppression of personal feelings.

5. A client recently had an abdominoperineal resection and colostomy. While the nurse changes the dressing, the client states, 'You think that it looks repulsive.' The nurse identifies that the client is using which defense mechanism?

• A. Projection
• B. Sublimation
• C. Compensation
• D. Intellectualization

Correct answer: A

Rationale: The correct answer is Projection. Projection is the defense mechanism where unacceptable feelings and emotions are attributed to others. In this scenario, the client is projecting their own feelings of repulsion onto the nurse. Sublimation involves substituting socially acceptable feelings to replace threatening ones. Compensation refers to overachievement in a different area to cover up a weakness. Intellectualization is the use of mental reasoning to avoid facing emotional aspects of a situation.

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