Nursing Elites

1. A client undergoing presurgical testing before a total abdominal hysterectomy says to the nurse, 'After I have this surgery I know my husband will never come near me again.' Which response would the nurse give?

• A. You're underestimating how your husband will respond to your surgery.
• B. You're concerned about the effect on your sexual relations.
• C. You're worried that the surgery will change how others see you.
• D. You're concerned about how your husband will respond to your surgery.

Correct answer: D

Rationale: The correct response acknowledges the client's expressed concern about her husband's reaction to the surgery, encouraging further discussion without imposing the nurse's assumptions. Choice A reframes the client's concern to focus on the husband's response, aligning more closely with the client's stated worry. Choice B makes an assumption about the client's concerns regarding sexual relations, which may not be the primary focus of her statement. Choice C shifts the attention to how others perceive the client, deviating from the client's specific reference to her husband's reaction, thus not addressing the client's main concern.

2. Which thought process would the nurse document the mental health client is experiencing after the client says, 'The FBI is out to kill me'?

• A. Hallucinations
• B. Error in judgment
• C. Delusion of persecution
• D. Self-accusatory delusion

Correct answer: C

Rationale: The nurse would document that the client is experiencing a delusion of persecution. A delusion of persecution is a fixed and firm belief of being harassed, in danger, or at the mercy of others, as illustrated by 'The FBI is out to kill me.' Hallucinations are perceived experiences that occur without actual sensory stimulation. Error in judgment refers to poor decision-making, not a distortion of reality like a delusion. A self-accusatory delusion involves accepting blame for an act that was never committed or a feeling that was never acted on. Therefore, the correct choice is 'Delusion of persecution.'

3. The client is 5 feet from the bathroom door when he states, 'I feel faint.' Before the nurse can get the client to a chair, the client starts to fall. What is the priority action for the nurse to take?

• A. Check the client's carotid pulse
• B. Encourage the client to get to the toilet
• C. In a loud voice, call for help
• D. Gently lower the client to the floor

Correct answer: D

Rationale: The priority action for the nurse is to gently lower the client to the floor (Option D). This action is crucial to prevent injury to both the client and the nurse. Lowering the client to the floor should be done when the client is unable to support his own weight, ensuring a safe position to prevent falls. Checking the client's carotid pulse (Option A) is important, but it should be performed after ensuring the client's safety. Encouraging the client to get to the toilet (Option B) is impractical as the client is already falling. Calling for help in a loud voice (Option C) may cause chaos and alarm other clients, making it a less suitable immediate action in this scenario.

4. Which of the following is an example of neurofeedback used with a child diagnosed with reactive attachment disorder (RAD)?

• A. A child's brain waves are monitored through electrodes placed on the scalp
• B. Parents give their child a sticker when he behaves appropriately
• C. A child uses a sand tray to draw shapes and release stress while talking with a nurse
• D. Parents or a nurse hold a child close during play until he becomes angry enough to unleash his rage

Correct answer: A

Rationale: Neurofeedback is a form of treatment that may be used for children diagnosed with reactive attachment disorder (RAD). Neurofeedback involves attaching electrodes to the scalp in a method similar to an EEG. The child's brainwaves are then monitored while being exposed to positive images or games to produce positive brain patterns. Choice A is the correct answer as it describes the process of neurofeedback, which is a common therapeutic approach for managing RAD. Choices B, C, and D are incorrect because they do not directly involve monitoring brain waves through electrodes to provide feedback for brain pattern adjustments, which is the core concept of neurofeedback therapy.

5. What is the primary purpose served when an individual takes action to reduce anxiety?

• A. Reduction of tension
• B. Denial of the situation
• C. Avoidance of physical discomfort
• D. Resolution in decision-making

Correct answer: A

Rationale: The primary purpose of taking action to reduce anxiety is to alleviate emotional tension and prevent the exacerbation of anxiety symptoms. By reducing tension, anxiety levels decrease, leading to a sense of comfort, safety, and security. Denial of the situation is not the goal when addressing anxiety; rather, acknowledging and managing it is crucial. While physical discomfort may accompany anxiety, the focus is on alleviating the emotional aspect to mitigate physical manifestations. Although mild anxiety can sometimes improve decision-making skills, higher levels of anxiety typically impede cognitive functions, making resolution in decision-making less likely.

Similar Questions