Nursing Elites

1. A client dies while several family members are in the room. Which intervention will the hospice nurse initially use during the shock phase of a grief reaction?

• A. Stay at the bedside with the family and the deceased.
• B. Direct activities related to funeral arrangements.
• C. Mobilize the support systems for the family.
• D. Present the full reality of the loss to the family.

Correct answer: A

Rationale: During the shock phase of a grief reaction, the hospice nurse's initial intervention should be to stay at the bedside with the family and the deceased. This action provides immediate support to the family until coping mechanisms and personal support systems can be mobilized. Directing activities related to funeral arrangements is not within the nurse's role and responsibility. Mobilizing the support systems for the family is important, but staying with the family and the deceased helps in providing immediate comfort and support. Presenting the full reality of the loss to the family is not appropriate during the shock phase as acceptance of the loss takes time and is not the immediate priority.

2. When a client who has had a mastectomy sees her incision for the first time, she exclaims, 'I look horrible! Will it ever look better?' Which response would the nurse provide?

• A. 'You seem shocked by the way you look now.'
• B. 'Now that the tumor is gone, the area will heal quickly.'
• C. After it heals, others won't even know you had surgery.'
• D. 'You will feel better about it when the swelling subsides.'

Correct answer: A

Rationale: The correct response, 'You seem shocked by the way you look now,' acknowledges the client's feelings and provides an opportunity for the client to express emotions freely. This reflection of feelings may help promote eventual acceptance of body image changes. Choices B, C, and D provide false reassurance and negate the client's feelings. Saying that the area will heal quickly now that the tumor is gone dismisses the client's concerns. Similarly, stating that others won't know about the surgery or that the client will feel better once the swelling subsides does not address the client's current emotional state and may undermine trust in the nurse-client relationship.

3. To reduce the risk of venous thrombosis, which measure should the nurse instruct the client in to promote venous return?

• A. Instruct in the use of the incentive spirometer.
• B. Elevate the head of the bed during all meals.
• C. Use aseptic technique to change the dressing.
• D. Encourage frequent ambulation in the hallway.

Correct answer: D

Rationale: To prevent venous thrombus formation, promoting venous return is crucial. Encouraging frequent ambulation in the hallway helps prevent venous stasis and reduces the risk of thrombus formation in immobile clients. Option A (using the incentive spirometer) aids in alveolar expansion to prevent atelectasis, not specifically venous thrombosis. Option B (elevating the head of the bed during meals) reduces the risk of aspiration, not venous thrombosis. Option C (using aseptic technique for dressing changes) reduces the risk of postoperative infection, not specifically venous thrombosis. Therefore, among the options provided, encouraging frequent ambulation in the hallway is the most effective measure to prevent venous thrombosis.

4. A 16-month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her, and begins to cry. What would be the initial action by the nurse?

• A. Arrange to change client care assignments.
• B. Explain that this behavior is expected.
• C. Discuss the appropriate use of 'time-out'.
• D. Explain that the child needs extra attention.

Correct answer: B

Rationale: The correct answer is to explain that this behavior is expected. During normal development, fear of strangers becomes prominent beginning around age 6-8 months. Such behaviors include clinging to parents, crying, and turning away from the stranger. These fears and behaviors extend into the toddler period and may persist into preschool. Changing client care assignments (Choice A) is not necessary as the child's behavior is developmentally appropriate. Discussing the appropriate use of 'time-out' (Choice C) is not relevant in this situation as the child is displaying normal attachment behavior, not misbehavior. Explaining that the child needs extra attention (Choice D) may not be necessary as the child is likely seeking comfort from the familiar presence of the mother, which is a typical response in a stressful situation like being in a hospital environment.

5. A client who has undergone a mastectomy because of breast cancer is now undergoing chemotherapy, which has caused hair loss. The client states, 'I feel like I've lost my sense of power.' Which response would the nurse give?

• A. 'Hair does not empower a person.'
• B. 'Losing power seems important to you.'
• C. Knowledge is power; I'll give you some pamphlets to read.'
• D. 'Hair loss is common; it will grow back, so you should not worry.'

Correct answer: B

Rationale: The correct response is, 'Losing power seems important to you.' This response acknowledges the client's feelings and provides an opportunity for further discussion. Choice A is confrontational and dismissive, potentially shutting down communication. Choice C offers pamphlets, which may be seen as dismissing the client's concerns and avoiding engaging in a conversation. Choice D minimizes the client's feelings and may discourage further expression of emotions. By choosing option B, the nurse shows empathy and encourages the client to explore their emotions in a supportive environment.

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