Nursing Elites

1. A 17-year-old female was raped by a young man in her neighborhood. She is in the Emergency Department for evaluation and tests. After the procedure is completed, a rape crisis counselor (nurse specialist) talks to the client in a conference room regarding the rape. Implementing counseling by the nurse specialist for the raped victim represents:

• A. assessment.
• B. crisis intervention.
• C. empathetic concern.
• D. unwarranted intrusion

Correct answer: B

Rationale: Crisis intervention is the correct choice. Counseling by a nurse specialist after a traumatic event like rape falls under the Crisis Intervention Model. This approach aims to provide immediate support to individuals facing a crisis to enhance coping mechanisms. In this scenario, the nurse specialist is offering specialized care tailored to rape victims, helping the client navigate through the emotional aftermath of the traumatic experience. Choices A, C, and D are incorrect: A is not the correct answer as the nurse specialist is providing emotional support rather than conducting an assessment; C, while important, does not fully capture the specialized intervention being provided; and D is inaccurate as the nurse specialist's intervention is warranted and essential for the victim's well-being.

2. After delivering a healthy newborn 1 hour ago, a nurse notes a woman's radial pulse rate is 55 beats/min. What action should the nurse take based on this finding?

• A. Reporting the finding to the healthcare provider immediately
• B. Helping the woman stay in bed and rest
• C. Documenting the finding
• D. Performing active and passive range-of-motion exercises

Correct answer: C

Rationale: After delivery, bradycardia (pulse rate 50-70 beats/min) may occur, reflecting the large amount of blood returning to the central circulation after delivery of the placenta. The increase in central circulation results in increased stroke volume, allowing a slower heart rate to provide adequate maternal circulation. A pulse rate of 55 beats/min falls within the normal range post-delivery, so there is no need to notify the healthcare provider immediately. It is important for the client to remain on bed rest in the immediate postpartum period to prevent complications. While range-of-motion exercises are beneficial for a client on bed rest, it is not the priority based on the data provided. Therefore, the most appropriate nursing action is to document the finding for accurate record-keeping and monitoring of the client's condition.

3. When evaluating a kinetic family drawing, which of the following actions is most effective?

• A. asking the child to draw their family doing something
• B. offering specific suggestions of what to include in the drawing
• C. discouraging the child from talking about the drawing
• D. noting the omission of any family members

Correct answer: D

Rationale: When evaluating a kinetic family drawing, noting the omission of any family members is an effective action. It is crucial to observe and analyze all aspects of the drawing, including what is missing. This can provide valuable insights into the child's perception and relationships within the family. Asking the child to draw their family doing something (Choice A) is more related to initial instruction rather than evaluation. Offering specific suggestions (Choice B) can influence the child's drawing and should be avoided to maintain the authenticity of the representation. Discouraging the child from talking about the drawing (Choice C) is counterproductive as verbal expression can provide additional context and understanding.

4. The LPN is taking care of a client who is on Phenelzine (Nardil) for depression. Which meal would the nurse encourage the client to avoid?

• A. steak and potatoes
• B. prosciutto and cheese plate
• C. orange juice and toast
• D. carbonated water, shrimp and rice

Correct answer: B

Rationale: The correct answer is 'prosciutto and cheese plate.' Phenelzine (Nardil) is an MAOI (Monoamine Oxidase Inhibitor), and clients on these drugs should avoid foods high in tyramine due to the risk of dangerous elevations in blood pressure. Prosciutto and aged cheeses are examples of foods rich in tyramine, so they should be avoided. Choices A, C, and D do not contain high levels of tyramine and are considered safe to consume while on Phenelzine.

5. When evaluating a kinetic family drawing, which of the following nursing actions is most effective?

• A. instructing the child to draw their family doing something
• B. suggesting specific elements to include in the drawing
• C. discouraging the child from discussing the drawing
• D. noting the omission of any family members

Correct answer: D

Rationale: When evaluating a kinetic family drawing, the most effective nursing action is noting the omission of any family members. This approach helps healthcare providers gather crucial information about family dynamics. It is important to pay attention to what the child includes and omits in the drawing, as it can provide insights into underlying emotions and concerns. Choices A, B, and C are not recommended actions for evaluating the drawing. Instructing the child to draw their family doing something or suggesting specific elements to include may bias the drawing, leading to misinterpretations. Discouraging the child from discussing the drawing can impede communication and the understanding of the child's perspective.

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