Nursing Elites

1. A man who is admitted for a suicide attempt after the death of his child says, 'I hear my son telling me to come over to the other side.' Which psychotic symptom is the client experiencing?

• A. Fixed delusion
• B. Magical thinking
• C. Pathological regression
• D. Command hallucination

Correct answer: D

Rationale: The client is experiencing a command hallucination. Command hallucinations involve auditory messages instructing harm to self or others, and giving an identity to the hallucinated voice increases the risk of compliance. A fixed delusion is a false belief held to be true despite evidence to the contrary. Magical thinking involves believing that thoughts can influence events, commonly seen in young children. Pathological regression refers to reverting to a previous developmental stage, not applicable in this scenario.

2. An ambulatory client reports edema during the day in his feet and an ankle that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask?

• A. Have you had a recent heart attack?
• B. Do you become short of breath during your normal daily activities?
• C. How many pillows do you use at night to sleep comfortably?
• D. Do you smoke?

Correct answer: B

Rationale: The correct answer is asking about shortness of breath during normal daily activities because these symptoms suggest right-sided heart failure, leading to increased pressure in the systemic venous system. This pressure causes fluid to shift into the interstitial spaces, resulting in edema. In an ambulatory patient, lower extremities are typically affected first due to gravity. By asking about shortness of breath, the nurse can gather information to confirm the nursing diagnosis of activity intolerance and fluid volume excess, both associated with right-sided heart failure. The other choices are less relevant in this context and do not directly address the client's presenting symptoms.

3. What nonverbal action should the nurse implement to demonstrate active listening?

• A. Sit facing the client.
• B. Cross arms and legs.
• C. Avoid eye contact.
• D. Lean back in the chair.

Correct answer: A

Rationale: Active listening is effectively demonstrated through attentive verbal and nonverbal communication strategies. To convey active listening and show the client that the nurse is engaged and attentive, it is essential for the nurse to sit facing the client. This posture communicates openness and willingness to listen. Option B, crossing arms and legs, creates a barrier and can signal defensiveness or disinterest, making it an incorrect choice. Option C, avoiding eye contact, hinders the establishment of a connection and can convey disengagement. Option D, leaning back in the chair, may give the impression of disinterest or lack of engagement. Therefore, maintaining eye contact and sitting facing the client are crucial nonverbal actions to exhibit active listening and promote effective therapeutic communication.

4. What initial response would the nurse give to a husband who is upset that his wife's alcohol withdrawal delirium has persisted for a second day?

• A. "I see that you're worried. We're using medication to ease your wife's discomfort."?
• B. "This is expected. I suggest that you go home because there's nothing you can do to help."?
• C. "If you're afraid that she will die, I assure you, very few alcoholics die during detoxification."?
• D. "If you are concerned that she is uncomfortable, I'm sure that she's not in pain."?

Correct answer: A

Rationale: The correct response is to acknowledge the husband's feelings and provide information on the treatment plan to alleviate his concerns. This approach validates his emotions and educates him on the steps being taken to help his wife, promoting understanding and reducing anxiety. Choice B is incorrect as it dismisses the husband's worries and implies helplessness, potentially increasing his distress. Choice C is inappropriate as it introduces the concept of death, which can heighten fear and anxiety in the husband. Choice D is not recommended as it provides reassurance about the wife's pain without accurate knowledge of her discomfort, which could undermine trust and communication between the nurse and the husband.

5. A client with untreatable metastasized cancer tells the nurse, 'I think they made a mistake. I don't think I have cancer. I feel too good to be dying.' Which stage of grief is the client experiencing?

• A. Anger
• B. Denial
• C. Bargaining
• D. Acceptance

Correct answer: B

Rationale: The client is experiencing the stage of denial. This is evident as the client is having difficulty accepting the reality of their diagnosis and denies the presence of cancer despite the evidence. During the anger stage, the individual expresses anger about their situation, questioning why it is happening to them. Bargaining involves attempting to negotiate for more time or a different outcome, acknowledging the reality of death but trying to delay it. Acceptance, on the other hand, is characterized by coming to terms with the inevitability of death and preparing for it peacefully. Therefore, in this scenario, the client's disbelief and refusal to accept the diagnosis align with the denial stage of grief.

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