Nursing Elites

1. A client who exhibits blurred and double vision and muscular weakness is informed of the diagnosis of multiple sclerosis (MS). The client becomes visibly upset. Which response would the nurse make?

• A. That must have shocked you. Tell me what the health care provider told you about it.
• B. You should see a psychiatrist who will help you cope with this overwhelming news.
• C. Don't worry; early treatment often alleviates the symptoms of the disease.
• D. You should be glad that we caught it early so you can be cured.

Correct answer: A

Rationale: The response 'That must have shocked you. Tell me what the health care provider told you about it' acknowledges the effect of the diagnosis on the client and explores what is known. This response shows empathy and encourages the client to share their understanding. There is no evidence of ineffective coping, so a referral to a psychiatrist is not necessary at this initial stage. The statement 'Don't worry; early treatment often alleviates symptoms of the disease' provides false reassurance as the course of MS varies for each individual and may not always respond well to treatment. The statement 'You should be glad we caught it early so it can be cured' does not address the client's current emotional state and is inaccurate; MS is a chronic autoimmune disease that currently has no cure.

2. A client is discussing his personal feelings of self-esteem and self-concept with a nurse. Which of the following questions is most appropriate for assessing the client's personal identity?

• A. What is your educational background?
• B. Are your parents still living?
• C. What do you like about your life right now?
• D. Where do you see yourself in 10 years?

Correct answer: C

Rationale: When assessing a client's personal identity, it is essential for the nurse to inquire about aspects related to the client's self-perception and self-worth. Asking about what the client likes about his current life helps to explore his positive self-perceptions and areas of contentment. This question encourages the client to reflect on his present circumstances and identify aspects that contribute to his sense of personal identity. Choices A, B, and D are not as relevant for assessing personal identity as they focus on educational background, parental status, and future aspirations, respectively, rather than directly addressing the client's current self-perception and identity.

3. A 9-year-old boy is told that he must stay in the hospital for at least 2 weeks. The nurse finds him crying and unwilling to talk. What is the priority nursing care at this time?

• A. Assuring him that his illness is not permanent
• B. Distracting him to prevent further embarrassment
• C. Arranging for him to receive tutoring immediately
• D. Providing privacy to allow him to express his feelings

Correct answer: D

Rationale: The priority nursing care for a 9-year-old child who is crying and unwilling to talk in the hospital is to provide privacy to allow him to express his feelings. Children need an opportunity to express their emotions in private, and talking about their feelings can be therapeutic. Assurances about the illness not being permanent may not be the child's primary concern at this moment. Distracting the child could give the impression that crying is wrong. Arranging tutoring does not address the immediate emotional needs of the child.

4. A client recently had an abdominoperineal resection and colostomy. While the nurse changes the dressing, the client states, 'You think that it looks repulsive.' The nurse identifies that the client is using which defense mechanism?

• A. Projection
• B. Sublimation
• C. Compensation
• D. Intellectualization

Correct answer: A

Rationale: The correct answer is Projection. Projection is the defense mechanism where unacceptable feelings and emotions are attributed to others. In this scenario, the client is projecting their own feelings of repulsion onto the nurse. Sublimation involves substituting socially acceptable feelings to replace threatening ones. Compensation refers to overachievement in a different area to cover up a weakness. Intellectualization is the use of mental reasoning to avoid facing emotional aspects of a situation.

5. The nurse is preparing to administer 10 mL of liquid potassium chloride through a feeding tube, followed by 10 mL of liquid acetaminophen. Which action should the nurse include in this procedure?

• A. Dilute each of the medications with sterile water prior to administration.
• B. Mix the medications in one syringe before opening the feeding tube.
• C. Administer water between the doses of the two liquid medications.
• D. Withdraw any fluid from the tube before instilling each medication.

Correct answer: C

Rationale: Water should be instilled into the feeding tube between administering the two medications to maintain the patency of the feeding tube and ensure that the total dose of medication enters the stomach and does not remain in the tube. These liquid medications do not need to be diluted when administered via a feeding tube. Mixing the medications in one syringe can lead to interactions or alterations in the medications' properties. Withdrawing any fluid from the tube before instilling each medication can cause inaccurate dosing and incomplete administration. Therefore, the correct action is to administer water between the doses of the two liquid medications to ensure proper delivery and avoid any complications.

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