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. Upon admission, a female client with breast cancer, liver, and spine metastases presents with constant, severe pain despite the continuous use of oxycodone (Percodan) and amitriptyline (Elavil) at home for pain management. What information is most crucial for the nurse to gather during the admission assessment?

• A. Sensory pattern, area, intensity, and nature of the pain.
• B. Identification of trigger points through palpation and manual pressure on painful areas.
• C. Current schedule and total dosages of medications used for breakthrough pain.
• D. Assessment of sympathetic responses indicative of acute pain onset.

Correct answer: A

Rationale: The most critical information for the nurse to obtain during the admission assessment of a client with severe pain due to breast cancer metastasis to the liver and spine is the sensory pattern, area, intensity, and nature of the pain. Understanding these details is essential to tailor appropriate pain management therapy effectively. By assessing the sensory pattern, area, intensity, and nature of pain, the nurse can better determine the underlying cause and choose the most suitable interventions to address the client's pain and improve their quality of life. Trigger points, medication dosages, and sympathetic responses are also important aspects of pain assessment but understanding the sensory aspects of pain is fundamental for providing optimal care in this scenario.

3. A client is receiving total parenteral nutrition (TPN). Which assessment finding is most concerning to the nurse?

• A. Blood glucose level of 150 mg/dL.
• B. Blood pressure of 110/70 mm Hg.
• C. Serum albumin level of 3.5 g/dL.
• D. The client's temperature is 100.4°F (38°C).

Correct answer: D

Rationale: A temperature of 100.4°F (38°C) (D) is the most concerning finding for a client receiving total parenteral nutrition (TPN) as it may indicate an infection, which poses a significant risk. Monitoring blood glucose level (A), blood pressure (B), and serum albumin (C) are also important, but an elevated temperature suggests a potential serious complication that requires immediate attention.

4. During the admission assessment of a terminally ill male client, he states that he is an agnostic. What is the best nursing action in response to this statement?

• A. Provide information about the hours and location of the chapel
• B. Document the statement in the client’s spiritual assessment
• C. Invite the client to a healing service for people of all religions
• D. Offer to contact a spiritual advisor of the client’s choice

Correct answer: B

Rationale: Documenting the client's statement in the spiritual assessment is the best nursing action in response to his disclosure of being an agnostic. This respects the client's beliefs and preferences, ensuring that care is tailored to his individual needs. It also demonstrates a commitment to providing holistic and patient-centered care. Providing information about the chapel's hours and location (choice A) may not align with the client's beliefs as an agnostic. Inviting the client to a healing service (choice C) assumes the client's interest in such activities, which may not be the case. Offering to contact a spiritual advisor (choice D) may not be necessary if the client did not express a desire for it.

5. The client, who is newly diagnosed with arteriosclerosis and is obese, is being educated by the nurse on reducing the risk of a heart attack or stroke. Which health promotion brochure should the nurse provide to this client?

• A. Monitoring Your Blood Pressure at Home
• B. Smoking Cessation as a Lifelong Commitment
• C. Decreasing Cholesterol Levels Through Diet
• D. Stress Management for a Healthier You

Correct answer: C

Rationale: The most significant risk factor contributing to arteriosclerosis is excess dietary fat, particularly saturated fat and cholesterol. Therefore, the most crucial brochure for the nurse to provide to the client focuses on decreasing cholesterol levels through diet to help reduce the risk of heart attack or stroke.

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