Nursing Elites

1. What nonverbal action should the nurse implement to demonstrate active listening?

• A. Sit facing the client.
• B. Cross arms and legs.
• C. Avoid eye contact.
• D. Lean back in the chair.

Correct answer: A

Rationale: Active listening is effectively demonstrated through attentive verbal and nonverbal communication strategies. To convey active listening and show the client that the nurse is engaged and attentive, it is essential for the nurse to sit facing the client. This posture communicates openness and willingness to listen. Option B, crossing arms and legs, creates a barrier and can signal defensiveness or disinterest, making it an incorrect choice. Option C, avoiding eye contact, hinders the establishment of a connection and can convey disengagement. Option D, leaning back in the chair, may give the impression of disinterest or lack of engagement. Therefore, maintaining eye contact and sitting facing the client are crucial nonverbal actions to exhibit active listening and promote effective therapeutic communication.

2. Nursing behaviors associated with the implementation phase of the nursing process are concerned with:

• A. participating in the mutual identification of patient outcomes.
• B. gathering accurate and sufficient patient-centered data.
• C. comparing patient responses and expected outcomes.
• D. carrying out interventions and coordinating care.

Correct answer: D

Rationale: During the implementation phase of the nursing process, nurses focus on executing interventions and coordinating care. This involves utilizing available resources, performing necessary interventions, exploring alternatives when needed, and collaborating with other healthcare team members to ensure comprehensive care delivery. Choice A is incorrect as it pertains more to the planning phase where patient outcomes are identified. Choice B is incorrect as it relates to data collection, which is primarily a part of the assessment phase. Choice C is incorrect as it involves evaluating patient responses against expected outcomes, which is part of the evaluation phase.

3. A 65-year-old client who attends an adult daycare program and is wheelchair-mobile has redness in the sacral area. Which instruction is most important for the nurse to provide?

• A. Take a vitamin supplement tablet once a day.
• B. Change positions in the chair at least every hour.
• C. Increase daily intake of water or other oral fluids.
• D. Purchase a newer model wheelchair.

Correct answer: B

Rationale: The most important instruction for the nurse to provide to the client is to change positions in the chair at least every hour. This is crucial to prevent pressure ulcers, as prolonged pressure on the skin can lead to tissue damage. Repositioning helps relieve pressure on vulnerable areas like the sacrum. Increasing fluid intake can also aid in preventing skin breakdown by maintaining skin hydration. While a vitamin supplement may support overall health, it is not as critical as repositioning to prevent pressure ulcers. Purchasing a new wheelchair is an expensive intervention and should be considered a last resort after implementing less costly preventive measures.

4. What psychodynamic process is suggested by a client calling the emergency department during a suicide attempt?

• A. A cry for help
• B. A need for attention
• C. Ambivalence about dying
• D. An inability to stick to a decision

Correct answer: C

Rationale: The correct answer is 'Ambivalence about dying.' When a client calls the emergency department during a suicide attempt, it suggests conflicting feelings about living and dying. This act can indicate an unconscious desire to be stopped from dying, showing ambivalence between the wish to die and the wish to live. It is not primarily a cry for attention or a need to punish others. The client's intention of suicide alongside seeking help demonstrates the struggle between life and death, making ambivalence the key psychodynamic process at play.

5. The client is 5 feet from the bathroom door when he states, 'I feel faint.' Before the nurse can get the client to a chair, the client starts to fall. What is the priority action for the nurse to take?

• A. Check the client's carotid pulse
• B. Encourage the client to get to the toilet
• C. In a loud voice, call for help
• D. Gently lower the client to the floor

Correct answer: D

Rationale: The priority action for the nurse is to gently lower the client to the floor (Option D). This action is crucial to prevent injury to both the client and the nurse. Lowering the client to the floor should be done when the client is unable to support his own weight, ensuring a safe position to prevent falls. Checking the client's carotid pulse (Option A) is important, but it should be performed after ensuring the client's safety. Encouraging the client to get to the toilet (Option B) is impractical as the client is already falling. Calling for help in a loud voice (Option C) may cause chaos and alarm other clients, making it a less suitable immediate action in this scenario.

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