Nursing Elites

1. 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.

2. During a discussion about glaucoma at the community center, which comment by one of the retirees would the nurse give a supportive comment to reinforce correct information?

• A. ''I usually avoid driving at night since lights sometimes seem to make things blur.''
• B. ''I take half of the usual dose for my sinuses to maintain my blood pressure.''
• C. ''I have to sit at the side of the pool with the grandchildren since I can't swim with this eye problem.''
• D. ''I take extra fiber and drink lots of water to avoid getting constipated.''

Correct answer: D

Rationale: The correct answer is ''I take extra fiber and drink lots of water to avoid getting constipated.'' In individuals with glaucoma, activities that involve straining, such as constipation, should be avoided as they can increase intraocular pressure. Choices A, B, and C are incorrect as they do not align with the management of glaucoma. Driving at night or taking sinus medication are not directly related to glaucoma, and sitting by the pool due to an eye problem does not provide information relevant to managing glaucoma.

3. The parents tell the nurse that their preschooler often awakes from sleep screaming in the middle of the night. The preschooler is not easily comforted and screams if the parents try to restrain the child. What should the nurse instruct the parents to do?

• A. Always read a story to the child before bedtime.
• B. Intervene only if necessary to protect the child from injury.
• C. Discuss counseling options with the primary health care provider.
• D. Try to wake the child and ask the child to describe the dream.

Correct answer: B

Rationale: Waking up screaming from sleep at night indicates sleep terrors. The nurse would advise the parents to observe the child and intervene only if there is a risk for injury. Reading a story before bedtime helps calm the child before sleeping, but it does not ensure that the child will not have a sleep terror. There is no need for professional counseling because sleep terrors are a common phenomenon in preschool-age children. Trying to wake the child and asking the child to describe the dream is not appropriate as the child is not aware of anybody's presence during a sleep terror, and this may cause the child to scream and thrash more.

4. A staff nurse expresses frustration that a Native American patient always has several family members at the bedside. Which action by the charge nurse is most appropriate?

• A. Remind the nurse that family support is important to this family and patient.
• B. Have the nurse explain to the family that too many visitors will tire the patient.
• C. Suggest that the nurse ask family members to leave the room during patient care.
• D. Ask about the nurse's personal beliefs about family support during hospitalization.

Correct answer: D

Rationale: The first step in providing culturally competent care is to understand one's own beliefs and values related to health and health care. Asking the nurse about personal beliefs will help achieve this step. Reminding the nurse that this cultural practice is important to the family and patient will not decrease the nurse's frustration. The remaining responses, such as suggesting that the nurse ask family members to leave the room or having the nurse explain to the family that too many visitors will tire the patient, are not culturally appropriate for this patient.

5. In the care of a withdrawn, reclusive psychotic client, which goal is the priority?

• A. Establish trust
• B. Increase feelings of self-worth
• C. Solidify sense of identity
• D. Improve ability to socialize

Correct answer: A

Rationale: The priority goal in the care of a withdrawn, reclusive psychotic client is to establish trust. Trust is fundamental in building a therapeutic relationship, which is essential for effective care. Without trust, the client may not engage in therapy or interventions. Once trust is established, the nurse can then assess the client's feelings of self-worth, sense of identity, and ability to socialize. While these other goals are important in the overall care of the client, establishing trust forms the foundation for further progress in the therapeutic relationship and treatment.

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