Nursing Elites

1. A client has a nursing diagnosis of 'spiritual distress.' What intervention is best for the nurse to implement when caring for this client?

• A. Use distraction techniques during times of spiritual stress and crisis.
• B. Reassure the client that their faith will be regained with time and support.
• C. Consult with the staff chaplain and request that the chaplain visit with the client.
• D. Use reflective listening techniques when the client expresses spiritual doubts.

Correct answer: D

Rationale: When a client is going through spiritual distress, employing reflective listening techniques is crucial. This method allows the client to voice their concerns and emotions, providing them with a supportive environment to explore their feelings. Options A and B do not directly address the client's spiritual distress and may undermine the client's feelings. While option C involves a chaplain, using reflective listening directly involves the nurse in addressing and supporting the client's spiritual concerns.

2. A client with a suspected kidney infection is admitted to the hospital for observation. Which action should the nurse implement to assess the client’s kidney function?

• A. Monitor the client’s urine output
• B. Check for abdominal tenderness
• C. Evaluate the client’s fluid intake
• D. Inspect the client’s skin for edema

Correct answer: A

Rationale: Monitoring urine output is the most direct way to assess kidney function as it provides crucial information about the kidneys’ ability to filter waste and produce urine. Changes in urine output can indicate potential issues with kidney function, such as decreased filtration or impaired excretion of waste products.

3. After informing an older client that an IV line needs to be inserted, the client becomes very apprehensive, loudly expressing a dislike for all healthcare providers and nurses. How should the nurse respond?

• A. Ask the client to remain quiet so the procedure can be performed safely.
• B. Concentrate on completing the insertion as efficiently as possible.
• C. Calmly reassure the client that the discomfort will be temporary.
• D. Tell the client a joke as a means of distraction from the procedure.

Correct answer: C

Rationale: In this situation, the nurse should respond by calmly reassuring the client that the discomfort from the IV insertion will be temporary. By providing reassurance and addressing the client's concerns, the nurse can help reduce the client's apprehension and create a more supportive environment for the procedure.

4. When a health care provider diagnoses metastatic cancer and recommends a gastrostomy for an older female client in stable condition, the son tells the nurse that his mother must not be told the reason for the surgery because she 'can't handle' the cancer diagnosis. Which legal principle is the court most likely to uphold regarding this client's right to informed consent?

• A. The family cannot provide the consent required in this situation because the older adult is in a condition to make such decisions.
• B. Because the client is mentally incompetent, the son does not have the right to waive informed consent for her.
• C. The court will not allow the health care provider to make the decision to withhold informed consent under therapeutic privilege.
• D. If informed consent is withheld from a client, health care providers could be found guilty of negligence.

Correct answer: D

Rationale: In the scenario described, it is crucial for health care providers to obtain informed consent from the client before proceeding with any medical intervention. If informed consent is withheld and the treatment is carried out without the client's agreement, health care providers could be found guilty of negligence, specifically assault and battery. This legal principle emphasizes the importance of respecting a client's autonomy and right to make decisions about their own healthcare. Despite the son's wishes to withhold information from his mother, the client must be informed of the proposed treatment and given the opportunity to consent or refuse based on complete information provided by the healthcare team.

5. What assessment finding places a client at risk for problems associated with impaired skin integrity?

• A. Scattered macules on the face
• B. Capillary refill of 5 seconds
• C. Smooth nail texture
• D. Presence of skin tenting

Correct answer: B

Rationale: The correct answer is B. A capillary refill time greater than 3 seconds indicates poor perfusion, leading to impaired skin integrity. Delayed capillary refill can compromise blood flow to the skin, increasing the risk of pressure ulcers or wounds due to reduced tissue perfusion. Choices A, C, and D are incorrect because scattered macules on the face, smooth nail texture, and presence of skin tenting are not direct indicators of impaired skin integrity or risk for skin problems.

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