Nursing Elites

1. A 26-year-old single woman is knocked down and robbed while walking her dog one evening. Three months later, she presents at the crisis clinic, stating that she cannot put this experience out of her mind. She complains of nightmares, extreme fear of being outside or alone, and difficulty eating and sleeping. What is the best response by the nurse?

• A. "I will ask the physician to prescribe medication for you."?
• B. "That must have been a very difficult and frightening experience. It might be helpful to talk about it."?
• C. "In the future, you might walk your dog in a more populated area or hire someone else to take over this task."?
• D. "Have you thought of moving to a safer neighborhood?"?

Correct answer: B

Rationale: Choice B is the best response as it provides empathy and encourages the client to talk about her experience, which can be therapeutic. This approach validates the client's feelings and offers support. By acknowledging the difficulty and fear experienced by the client, the nurse opens the door for the client to express her emotions and begin the process of coping with the trauma. Choices A, C, and D do not address the emotional impact of the traumatic event or provide an opportunity for the client to express her feelings and concerns. Choice A immediately jumps to medication without exploring other supportive interventions. Choice C focuses on practical solutions without addressing the client's emotional needs. Choice D suggests a drastic solution without considering the client's emotional state or preferences.

2. Referral for client education in the community can be accomplished through all of the following except:

• A. community agencies such as the American Heart Association
• B. parish nurses
• C. home health care agencies
• D. unlicensed massage therapists

Correct answer: D

Rationale: Client education should be conducted by individuals with acknowledged expertise in the subject area and appropriate credentials to support their activities within the healthcare community. Choices A, B, and C involve reputable entities or professionals who can provide accurate and reliable client education. The American Heart Association, parish nurses, and home health care agencies are recognized for their healthcare-related knowledge and qualifications. However, unlicensed massage therapists lack the necessary qualifications and expertise to deliver appropriate healthcare-related education, making them unsuitable for referrals when it comes to client education in the community.

3. A home health nurse is planning for her daily visits. Which client should the home health nurse visit first?

• A. A client with AIDS being treated with Foscarnet
• B. A client with a fractured femur in a long leg cast
• C. A client with laryngeal cancer with a laryngectomy
• D. A client with diabetic ulcers on the left foot

Correct answer: C

Rationale: The correct answer is the client with laryngeal cancer who had a laryngectomy. This client is at risk for airway obstruction due to the surgical procedure, making it a priority visit. Clients with AIDS (choice A), a fractured femur (choice B), and diabetic ulcers (choice D) do not have immediate life-threatening conditions that require urgent attention compared to a client with a recent laryngectomy.

4. A health care worker is concerned about a new mother being overwhelmed by caring for her infant. The health care worker should:

• A. immediately contact child protective services
• B. provide the mother with literature about child care
• C. consult a therapist to help the mother work out her fears
• D. refer the mother to parenting classes

Correct answer: D

Rationale: Prevention of child abuse is centered on teaching parents how to care for their child and cope with the demands of infant care. Parenting classes can help build self-confidence, self-esteem, and coping skills. Parents benefit by understanding the developmental needs of their children, while learning how to manage their home environment more effectively. The classes also increase the parents' social contacts and teach about community resources. Contacting child protective services (Choice A) is not appropriate in this scenario as there is no indication of abuse or neglect. Providing literature (Choice B) may not be as effective as parenting classes in addressing the mother's concerns. Consulting a therapist (Choice C) may be beneficial for underlying mental health issues, but parenting classes specifically focus on child care and coping skills, making Choice D the most suitable option in this situation.

5. A client with pancreatitis has been transferred to the intensive care unit. Which order would the nurse anticipate?

• A. Blood pressure monitoring every 15 minutes
• B. Insertion of a Levine tube
• C. Continuous cardiac monitoring
• D. Administration of pain medication every 4 hours

Correct answer: B

Rationale: In a client with pancreatitis who frequently experiences nausea and vomiting, insertion of a Levine tube is often anticipated to decompress the stomach and rest the bowel, helping to alleviate symptoms. This intervention is crucial in managing the gastrointestinal symptoms associated with pancreatitis. Blood pressure monitoring every 15 minutes may be necessary in some cases, but it is not a routine order for pancreatitis, making option A less likely. Continuous cardiac monitoring could be required based on the individual's condition, but it is not typically the first priority in pancreatitis management, so option C is not the most anticipated order. While pain medication administration is essential for managing discomfort, the priority in this scenario, especially considering the symptoms of nausea and vomiting, would be decompression with a Levine tube to address gastrointestinal issues, making option D less likely.

Similar Questions