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. By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection?

• A. Mode of transmission
• B. Portal of entry
• C. Reservoir
• D. Portal of exit

Correct answer: A

Rationale: When the nurse rolls contaminated gloves inside-out, they are manipulating the mode of transmission in the chain of infection. The gloves, which are contaminated, act as a vehicle for transferring pathogens from the reservoir's portal of exit to a potential portal of entry. Choices B, C, and D are incorrect because the action of rolling contaminated gloves does not directly relate to the portal of entry, reservoir, or portal of exit in the chain of infection.

3. Which nurse statement defines boundaries in the orientation phase of the nurse-client relationship when talking to a depressed client who has just been admitted to the psychiatric unit?

• A. ''Tell me about the relationship that you have with your mother and father.''
• B. ''Hello! I'm Nurse Andrea. I'll introduce you around and help you settle in.''
• C. ''What is the main thing that you would like to work on during therapy?'
• D. ''I understand that you have been depressed. What can you tell me about that?'

Correct answer: B

Rationale: In the orientation phase of the nurse-client relationship, setting boundaries involves establishing the nurse's role and responsibilities while maintaining a professional distance. Option B demonstrates a clear boundary by introducing the nurse and offering assistance with settling in, which is appropriate for the initial phase of building rapport with the client. Choices A, C, and D delve into personal or therapeutic topics that are more suitable for the working phase of the relationship when the client's goals and problems are being addressed. Asking about the client's family relationships (Choice A), therapy focus (Choice C), or delving into the client's depression (Choice D) would be more relevant in later stages of the therapeutic process, once trust and rapport have been established during the orientation phase.

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. After a client has a spontaneous abortion at 12 weeks' gestation, the nurse notes that both she and her partner are visibly upset and crying. Which statement would be a therapeutic response?

• A. 'I'll be here if you want to talk.''
• B. 'Try to relax"?it'll speed up the healing process.''
• C. 'With any luck, you'll get pregnant again soon.''
• D. 'It's best that this happened early rather than having the baby die after it was born.''

Correct answer: A

Rationale: A therapeutic response in this situation is to offer support and empathy. Saying, 'I'll be here if you want to talk' gives the client and her partner the opportunity to express their emotions and seek comfort. It acknowledges their distress and assures them of the nurse's availability. Choice B, advising to relax to speed up the healing process, dismisses their current emotions and may hinder open communication. Choice C, suggesting getting pregnant again soon, minimizes their grief over the loss and may not be what the couple needs to hear at that moment. Choice D, stating it's best that the miscarriage happened early, is insensitive as it invalidates the couple's feelings of loss and grief. Grieving is a natural process, and the timing of the loss does not diminish its significance.

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