Nursing Elites

1. What step should be taken when administering ear drops to an adult client?

• A. Place the client in a side-lying position.
• B. Hold the dropper 1 cm above the ear canal.
• C. Place a cotton ball into the outermost canal.
• D. Pull the auricle down and back.

Correct answer: A

Rationale: The correct step when administering ear drops to an adult client is to place the client in a side-lying position (A). This position allows for easier administration of the drops and helps prevent spillage. The dropper should be held approximately 1 cm (½ inch) above the ear canal (B) to ensure accurate delivery of the medication. Placing a cotton ball into the outermost canal (C) is unnecessary and may interfere with the absorption of the ear drops. Pulling the auricle down and back (D) is a technique used for children younger than 3 years old to straighten the ear canal, but it is not necessary for adults and may cause discomfort.

2. 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.

3. A client comes into the emergency room and asks to see a doctor. He is anxious, visibly upset, and keeps looking behind him to the waiting room. When the nurse asks his chief complaint, he says, 'My roommate is trying to kill me.' Which of the following is the most appropriate initial response of the nurse?

• A. Just wait here and I will notify security.
• B. I'm going to speak with the physician about getting some medication that may help you.
• C. Why is your roommate trying to kill you?
• D. Have you called the police to report this?

Correct answer: C

Rationale: Upon initial assessment of a client who appears anxious and upset, with claims that need further exploration, the nurse's initial response should be to gather more information about the situation. By asking 'Why is your roommate trying to kill you?' the nurse shows empathy while trying to understand the patient's perspective. This open-ended question allows the nurse to assess the situation comprehensively. Options A and D jump to conclusions or suggest actions without understanding the situation. Option B focuses solely on medication without addressing the underlying issue. It is crucial to assess the situation further before taking any action or providing treatment.

4. A client at a local university claims to be the president of the university. Which type of delusion is the client displaying?

• A. Somatic
• B. Grandiose
• C. Erotomanic
• D. Persecutory

Correct answer: B

Rationale: The correct answer is 'Grandiose.' This type of delusion involves an exaggerated sense of self-importance, where the individual believes they are a prominent figure or possess special abilities. In this scenario, the client claiming to be the president of the university is displaying grandiose delusions. Somatic delusions relate to bodily functions or sensations, which are not present in this case. Erotomanic delusions involve the fixed belief that another person is in love with the individual, which is not applicable here. Persecutory delusions involve the belief that one is being targeted or conspired against, which is also not demonstrated in the given situation.

5. A man who is admitted for a suicide attempt after the death of his child says, 'I hear my son telling me to come over to the other side.' Which psychotic symptom is the client experiencing?

• A. Fixed delusion
• B. Magical thinking
• C. Pathological regression
• D. Command hallucination

Correct answer: D

Rationale: The client is experiencing a command hallucination. Command hallucinations involve auditory messages instructing harm to self or others, and giving an identity to the hallucinated voice increases the risk of compliance. A fixed delusion is a false belief held to be true despite evidence to the contrary. Magical thinking involves believing that thoughts can influence events, commonly seen in young children. Pathological regression refers to reverting to a previous developmental stage, not applicable in this scenario.

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