Nursing Elites

1. When working with a client diagnosed with Borderline Personality Disorder who frequently attempts self-harm, what is the best intervention to facilitate behavior change?

• A. Constantly observing the client to prevent self-harm.
• B. Enlisting the client in defining and describing harmful behaviors.
• C. Checking on the client every 15 minutes to ensure they are not engaging in harmful behavior.
• D. Removing all items from the environment that the client could use to harm themselves.

Correct answer: B

Rationale: The most effective intervention when working with clients who have a history of self-harm, like the client diagnosed with Borderline Personality Disorder, is to involve them actively in their treatment. By enlisting the client to define and describe the harmful behaviors, the client becomes an integral part of identifying triggers and understanding the underlying causes of their actions. This approach empowers the client, promotes self-awareness, and fosters a sense of control over their behaviors. Constantly observing the client (Choice A) may lead to a lack of trust and hinder the therapeutic relationship. Checking on the client every 15 minutes (Choice C) may disrupt the client's sense of autonomy and privacy. Removing all items from the environment that could be used for self-harm (Choice D) is a temporary solution and does not address the root causes of the behavior.

2. After group therapy, the female victim of intimate partner violence confides to the nurse that she does not feel in any immediate danger. Which of the following statements about victims of domestic violence is true?

• A. Victims of domestic violence are often the best predictors of their risk of harm.
• B. Victims of domestic violence often overestimate their safety risk.
• C. Victims of domestic violence are typically in a state of denial.
• D. Victims of domestic violence know that keeping peace with their partner is the best method of preventing another attack.

Correct answer: A

Rationale: Victims of domestic violence are often correct at predicting their risk of harm. It is crucial for the nurse to ensure that the client is expressing herself authentically and not downplaying any potential danger. While victims can be insightful about their risk, it's essential to involve proper authorities, such as the police, in situations of intimate partner violence to ensure safety and provide necessary support. Choice B is incorrect because victims may not necessarily overestimate their safety risk. Choice C is incorrect as not all victims are in a state of denial; some may recognize the dangers they face. Choice D is incorrect because victims may not believe that keeping peace with their partner is the best way to prevent future attacks, as each individual's situation and mindset vary.

3. Tricyclics (Antidepressants) can sometimes have which of the following adverse effects on patients diagnosed with depression?

• A. Shortness of breath
• B. Fainting
• C. Large intestine ulcers
• D. Distal muscular weakness

Correct answer: B

Rationale: The correct answer is 'Fainting.' Tricyclic antidepressants can cause fainting and hypotension as adverse effects. Shortness of breath (Choice A) is not a common side effect of tricyclics. Large intestine ulcers (Choice C) are not typically associated with tricyclic antidepressants. Distal muscular weakness (Choice D) is not a common adverse effect of tricyclics but is commonly associated with other medications.

4. The nurse is caring for a client with laryngeal cancer. Which finding ascertained in the health history would not be common for this diagnosis?

• A. Foul breath
• B. Dysphagia
• C. Diarrhea
• D. Chronic hiccups

Correct answer: C

Rationale: Diarrhea is not a common finding in clients with laryngeal cancer. Foul breath (A), dysphagia (B), and chronic hiccups (D) are expected findings associated with laryngeal cancer. Foul breath can result from tissue breakdown in the mouth and throat. Dysphagia, or difficulty swallowing, can occur due to the tumor's location affecting the swallowing mechanism. Chronic hiccups can be a symptom of irritation to the phrenic nerves from the cancer.

5. A 50-milliliter (ml) bolus of normal saline fluid is ordered by the physician. The physician wants it to infuse in 30 minutes. The nurse should set the pump rate at:

• A. 100 ml per hour for one hour.
• B. 60 ml per hour for one-half hour
• C. 120 ml per hour for one hour.
• D. 50 ml per hour for one hour.

Correct answer: A

Rationale: To infuse a 50 ml bolus in 30 minutes, the rate should be calculated as follows: 50 ml / 30 min = 100 ml per hour. Therefore, the correct answer is to set the pump rate at 100 ml per hour for one hour. Choice A is the correct rate based on the calculation. Choices B, C, and D all provide incorrect rates that do not match the physician's order. Choice B would only deliver 30 ml in 30 minutes, not the ordered 50 ml. Choice C would deliver 120 ml in one hour, which is 20 ml more than ordered. Choice D would only provide 25 ml over 30 minutes, not the full 50 ml prescribed.

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