Nursing Elites

1. A client asks a nurse, 'Do you think I should move back home after this procedure?' and the nurse responds by saying, 'Do you think you should move back home?' What type of therapeutic communication is the nurse representing?

• A. Observation
• B. Reflection
• C. Summarizing
• D. Validating

Correct answer: B

Rationale: The nurse is demonstrating the therapeutic communication technique of reflection. In this scenario, the nurse is redirecting the question back to the client, encouraging them to explore their thoughts and feelings about the situation. Reflection involves restating a statement or question in a way that prompts the client to consider their own answers, fostering self-awareness and insight. Observation involves stating facts, summarizing involves condensing information, and validating involves confirming the client's feelings or experiences, none of which are demonstrated in this interaction.

2. A nurse walks into a client's room to find the nursing assistant yelling, 'Sit back down or I won't help you eat, and then you will starve!' This type of behavior is known as:

• A. Psychological abuse
• B. Abandonment
• C. Material exploitation
• D. Physical abuse

Correct answer: A

Rationale: The correct answer is A: Psychological abuse. This behavior is classified as psychological abuse, which harms another person through words or threats. The nursing assistant's actions of yelling, making threats, and using food as a form of control fall under psychological abuse. Abandonment (choice B) refers to deserting or leaving a client without care, which is not the case in the scenario. Material exploitation (choice C) involves taking advantage of a person's assets or resources for personal gain, which is not evident here. Physical abuse (choice D) involves causing physical harm, which is not the primary issue in this situation. Therefore, the most appropriate classification for the behavior described in the scenario is psychological abuse.

3. Which action represents the evaluation stage of the plan of care?

• A. The nurse assigns a nursing diagnosis of Impaired Skin Integrity related to diminished skin circulation
• B. The nurse assesses the client's vital signs and asks about symptoms
• C. The nurse determines that the client is not meeting his set outcomes and makes revisions
• D. The nurse discusses the client's health history

Correct answer: C

Rationale: The correct answer is C. The evaluation stage of the nursing process involves reviewing the assessments, diagnoses, and interventions given to the client and then determining if the client is meeting expected outcomes. In this scenario, the nurse is assessing whether the client is meeting the outcomes set for their care plan and making revisions as needed. Choice A is incorrect as assigning a nursing diagnosis is part of the nursing diagnosis phase, not the evaluation phase. Choice B represents the assessment phase of the nursing process, not the evaluation phase. Choice D involves discussing the client's health history, which is more aligned with the assessment phase rather than the evaluation phase.

4. The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate?

• A. Unequal leg length
• B. Limited adduction
• C. Diminished femoral pulses
• D. Symmetrical gluteal folds

Correct answer: A

Rationale: The correct answer is 'Unequal leg length.' Shortening of a leg is a common sign of developmental dysplasia of the hip. Limited adduction (Choice B) may be present but is less specific to developmental dysplasia of the hip. Diminished femoral pulses (Choice C) are not typically associated with developmental dysplasia of the hip. Symmetrical gluteal folds (Choice D) are a normal finding and would not be expected in a patient with developmental dysplasia of the hip.

5. You are attempting to teach the wife of a Greek patient how to administer his gastrostomy tube feedings once he returns home. She smiles and nods through your explanations, but when you ask her for a return demonstration, she looks confused and shakes her head. Her daughter enters the room and states that she does not speak English. What would be most helpful in this situation?

• A. Teach the daughter instead
• B. Teach both and ask the daughter to translate for you
• C. Contact a home health agency to provide care
• D. Provide a pamphlet with detailed instructions

Correct answer: B

Rationale: Teaching both the patient's wife and the daughter is the best option in this situation. The daughter may not always be available, and the wife is eager to care for her husband at home. While a hospital interpreter is often preferred, asking the daughter to interpret is a good alternative. This approach allows the daughter to receive instruction and reinforce it for herself as she translates it to her mother. Contacting a home health agency may not be necessary if family members are willing and able to assist. Providing a pamphlet with detailed instructions would not be as effective in ensuring the wife fully understands the procedure and can carry it out correctly.

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