Nursing Elites

1. A client has fallen asleep in his bed in the hospital. His heart rate is 65 bpm, his muscles are relaxed, and he is difficult to arouse. Which stage of the sleep cycle is this client experiencing?

• A. Stage 1
• B. Stage 2
• C. Stage 3
• D. Stage 4

Correct answer: C

Rationale: The client in this scenario is experiencing stage 3 of the sleep cycle. In stage 3, the individual has moved into deeper stages of sleep, making it difficult to arouse. Characteristics of stage 3 include relaxed muscles, a decrease in vital signs, and being very still. Stage 3 is a phase of non-REM sleep where the client progresses towards REM sleep and vivid dreams. Choices A, B, and D are incorrect. Stage 1 is characterized by light sleep, stage 2 is a slightly deeper sleep with sleep spindles and K-complexes, and stage 4 is the deepest stage of sleep with the slowest brain waves.

2. An 86-year-old client with decreased visual acuity who uses a cane for mobility requires fall prevention education. What should the nurse teach this client to reduce the risk of falling at home?

• A. Take off shoes while in the house and wear only socks
• B. Limit activities to the lower level of the home
• C. Keep a lamp near the door of every room
• D. Install non-slip pads in the shower or bathtub

Correct answer: D

Rationale: To reduce the risk of falling at home for an elderly client with decreased visual acuity and using a cane for mobility, installing non-slip pads in the shower or bathtub is crucial. This measure helps prevent slips and falls in areas where water accumulation may occur. While taking off shoes and wearing socks may seem comfortable, it increases the risk of slipping. Limiting activities to the lower level of the home may restrict the client's independence and quality of life unnecessarily. Keeping a lamp near the door of every room may improve visibility but does not directly address the risk of falls associated with mobility and visual acuity issues.

3. Who is the center of care?

• A. The doctor
• B. The administrator
• C. The patient
• D. The nurse

Correct answer: C

Rationale: The PATIENT is the center of care and the core of the healthcare team. The PATIENT holds the utmost importance within the healthcare setting. Healthcare professionals collaborate as a team to effectively address the needs of the patient. The primary focus should always be on the patient, who plays a crucial role in decision-making. While other healthcare team members, such as doctors, nurses, and administrators, play vital roles, the patient remains the central figure. The patient has the fundamental right to receive quality care from all members of the healthcare team.

4. Assuming that an elderly patient will have a difficult time understanding the directions for how to take medication is an example of:

• A. Prejudice
• B. Stereotyping
• C. Encoding
• D. Rationalization

Correct answer: B

Rationale: Stereotyping is defined as providing a generalization about a person based on their culture or characteristics. In this scenario, assuming that an elderly patient will have difficulty understanding medication directions solely based on their age is an act of stereotyping. The healthcare provider is attributing a generalized trait to the patient without considering individual differences. Prejudice, on the other hand, involves forming a negative opinion about someone based on their heritage or culture, which is not evident in this situation. Encoding refers to the process of converting information into a form that can be stored in memory, and rationalization involves justifying one's behavior or decisions with logical reasons, neither of which are applicable in this context.

5. An older adult patient brought to the emergency department by a family member is wandering outside, saying, "I can't find my way home."? The patient is confused and unable to answer questions. What is the nurse's best action?

• A. Document the patient's mental status and obtain other assessment data from the family member.
• B. Record the patient's answers to questions on the nursing assessment form.
• C. Ask an advanced practice nurse to perform the assessment interview.
• D. Call for a mental health advocate to maintain the patient's rights.

Correct answer: A

Rationale: In this scenario, the patient is confused and unable to answer questions. When the patient is unable to provide information, it is important to use secondary sources such as family members. The nurse's best action is to document the patient's mental status and obtain additional assessment data from the family member. This approach will help gather relevant information about the patient's condition. Asking an advanced practice nurse to perform the assessment interview is not necessary as it is within the staff nurse's scope of practice. Calling for a mental health advocate is also unnecessary at this point as the priority is to assess the patient's condition and gather information from the family member.

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