Nursing Elites

1. A client is seen in the emergency room as a victim of suspected domestic violence. The nurse's aide brings the client to a center curtained area, gives her a gown to change into, and asks her to wait for the nurse. What is the most appropriate action of the nurse upon arrival?

• A. Ask the client to undress to assess for injuries
• B. Take the client into a private room
• C. Notify the police to file a report
• D. Notify the house supervisor to keep security on alert

Correct answer: B

Rationale: When dealing with a client suspected of domestic violence, it is crucial to provide privacy and a safe environment. Taking the client into a private room allows for a confidential conversation and assessment without compromising the client's safety or dignity. The nurse should prioritize creating a safe space for the client to share information and receive support. Notification of authorities should only occur once a thorough assessment has been conducted to ensure the client's safety and well-being. Option A is incorrect because asking the client to undress should be done with sensitivity and respect for the client's privacy, focusing on assessing injuries rather than visualizing them. Option C is premature as involving the police should be based on a comprehensive assessment and the client's consent. Option D is not the most immediate and direct action required to address the client's immediate needs in a suspected domestic violence situation.

2. Tommy R., your 68-year-old patient, is at risk for falls. He has fallen 3 times in the last month. You should keep Tommy's ______________ in order to prevent him from falling again.

• A. bedside rails up at all times
• B. bed in the low position
• C. call bell within reach
• D. family members in the room at all times

Correct answer: C

Rationale: To prevent falls, it is essential to keep the patient's call bell within reach so they can easily call for help when needed. This allows for timely assistance and can prevent falls. While low beds can reduce the severity of injuries in case of a fall, they do not prevent falls from happening. Having family members in the room at all times is not a realistic or practical solution. Side rails can actually increase the severity of falls as patients may attempt to climb over them, and using side rails as fall prevention is considered a restraint practice that can lead to entrapment and other risks.

3. A victim of a gunshot wound to the abdomen has been admitted to the hospital, accompanied by a police officer. When questioned, the officer states that the patient is a suspect in a homicide, which occurred as part of the same incident. A small child was killed as the result of a stray bullet. The patient is combative, yells that he's in pain and demands medication. What is your most appropriate response?

• A. Tell him you'll take care of him after your other patients
• B. Reinforce restraints
• C. Perform a pain assessment and administer pain medication
• D. Ask the officer for more details of the incident

Correct answer: C

Rationale: The most appropriate and caring response is to perform a pain assessment and administer the pain medication that has been ordered. Regardless of personal feelings about any given situation, the nurse's responsibility is to provide unbiased, appropriate, and supportive care, as stated in the American Nurses Association (ANA) Code of Ethics. Choice A is not appropriate as it disregards the patient's immediate need for pain relief. Choice B may escalate the situation and is not the priority in this case. Choice D is not the immediate action needed to address the patient's pain and distress.

4. The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse's response?

• A. Electrical energy fields
• B. Spinal column manipulation
• C. Mind-body balance
• D. Exercise of joints

Correct answer: B

Rationale: The focus of the nurse's response should be on spinal column manipulation when discussing chiropractic treatment for illnesses. Chiropractic theory emphasizes that misalignment of the vertebrae can interfere with the transmission of mental impulses between the brain and body organs, leading to diseases. Manipulation is aimed at reducing such misalignments, known as subluxations. While mind-body balance and exercise of joints are important aspects of holistic health, in the context of chiropractic treatment, the key intervention is spinal column manipulation to address vertebral misalignments. Therefore, choices A, C, and D are incorrect as they do not directly address the primary focus of chiropractic treatment.

5. An adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. Which of the following statements about the disease is correct?

• A. The condition is not caused by the student's competitive swimming schedule.
• B. The student will most likely not require surgical intervention.
• C. The student experiences pain in the inferior aspect of the knee.
• D. The student is not trying to avoid participation in physical education.

Correct answer: C

Rationale: Osgood-Schlatter disease occurs in adolescents during the rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing pain and swelling in the inferior aspect of the knee. The condition is commonly caused by activities that require repeated use of the quadriceps, such as track and soccer. Choice A is incorrect because Osgood-Schlatter disease is not specifically linked to competitive swimming. Choice B is incorrect as surgical intervention is not usually necessary for this condition. Choice D is incorrect as the student is not trying to avoid physical education but is restricted from participating in sports due to the diagnosis of Osgood-Schlatter disease.

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