Nursing Elites

1. A 28-year-old woman is recovering from her third consecutive spontaneous abortion in 2 years. Which is the most therapeutic nursing intervention for this client at her follow-up appointment?

• A. Focusing on the client's physical needs
• B. Encouraging the client to verbalize her feelings about the loss
• C. Reminding the client that she will be able to become pregnant again
• D. Encouraging the client to think of herself, her husband, and their future

Correct answer: B

Rationale: The most therapeutic nursing intervention for a client recovering from multiple spontaneous abortions is to encourage the client to verbalize her feelings about the loss. This allows the client to express and process her emotions, facilitating the grieving process and emotional healing. Focusing solely on the client's physical needs, as in choice A, overlooks the importance of addressing the emotional aspect of the client's experience. Choice C, reminding the client that she will be able to become pregnant again, fails to acknowledge the current loss and may minimize the client's feelings of grief. Choice D, encouraging the client to think of herself, her husband, and their future, does not directly address the client's immediate emotional needs related to the recent loss. Therefore, choice B is the most appropriate intervention to support the client in coping with her emotional distress.

2. The client finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse implement first?

• A. Instruct an unlicensed assistive personnel (UAP) to stay and keep talking to the client.
• B. Sit quietly in the client's room until the client leaves the bathroom.
• C. Allow the client to cry alone and leave the client in the bathroom.
• D. Talk to the client and attempt to find out why the client is crying.

Correct answer: D

Rationale: The nurse's first concern should be for the client's safety, so an immediate assessment of the client's situation is needed. Option D is the correct choice as it involves directly addressing the client's emotional state and attempting to understand the reason for the distress. In a vulnerable situation like this, the nurse should take the lead in assessing and communicating with the client. Option A is incorrect as it would delegate the responsibility to someone else when the nurse should be the one to initiate the assessment. Option B is inappropriate as it does not actively address the client's emotional needs or safety. Option C is also incorrect because leaving the client alone without further assessment could potentially endanger the client's well-being.

3. The mother of an infant in the neonatal intensive care unit expresses concern about her infant. Which nursing intervention best facilitates mother-infant bonding?

• A. Asking the mother to change her baby's diaper
• B. Assuring the mother that her baby is receiving excellent care
• C. Encouraging the mother to touch her baby whenever possible
• D. Keeping the mother informed about the care the nursing staff is providing her baby

Correct answer: C

Rationale: Encouraging the mother to touch her baby whenever possible is the best intervention to promote mother-infant bonding, especially when the infant is too ill to be held. Physical touch is a powerful way to establish a connection. Mother-infant bonding is a gradual process and encouraging touch can help initiate this bond. Asking the mother to change her baby's diaper is not the most appropriate action to promote bonding in this scenario. Assuring the mother about the care her baby is receiving is important but does not directly enhance bonding. Keeping the mother informed about the care her baby is receiving is crucial, but it alone does not actively foster bonding between the mother and infant.

4. Which response would the nurse make to a client who says, 'The voices say I'll be safe only if I stay in this room, wear these clothes, and avoid stepping on the cracks between the floor tiles'?

• A. Ask whether the voices are male or female and how many there are.
• B. Reassure the client by stating, 'I understand that these voices are real to you, but I want you to know that I don't hear them.'
• C. Offer false reassurance by saying, 'Don't worry"?I've locked the door to your room and won't let anyone in.'
• D. Encourage the client to leave the room and keep busy to distract from the voices.

Correct answer: B

Rationale: The response, 'I understand that these voices are real to you, but I want you to know that I don't hear them,' demonstrates empathy and validation of the client's experience while also gently bringing in the nurse's reality. This response acknowledges the client's feelings without reinforcing the hallucinations. Asking about the characteristics of the voices (Choice A) can inadvertently validate the hallucinations. Offering false reassurance (Choice B) may not be helpful as it does not address the client's distress. Encouraging the client to leave the room and keep busy (Choice D) is nontherapeutic as it disregards the client's experience and may increase anxiety.

5. Which activity would be most beneficial for a school-age client diagnosed with a chronic illness to enhance a sense of accomplishment?

• A. Wearing make-up
• B. Making up missed work
• C. Participating in sports activities
• D. Participating in creative activities

Correct answer: B

Rationale: Making up missed work is an essential activity that can help a school-age client diagnosed with a chronic illness feel a sense of accomplishment. By catching up on missed work, the child can regain a sense of control and productivity, which can be empowering during a challenging time. Wearing make-up is more related to personal grooming and self-expression, which may not directly contribute to a sense of accomplishment in this context. Participating in sports activities is beneficial for peer relationships and physical health but may not address the immediate need for accomplishment in the academic setting. Engaging in creative activities fosters cognitive development but may not directly address the sense of achievement associated with completing academic tasks.

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