Nursing Elites

1. While ambulating an unsteady client who begins to fall, which of the following actions should the nurse take?

• A. Allow the client to slide down their outstretched leg.
• B. Place their arms around the client to prevent the fall.
• C. Remain upright as the client falls toward them.
• D. Move quickly to a position in front of the client.

Correct answer: A

Rationale: When a client is falling, allowing them to slide down your leg can help control the descent and prevent injury. This technique ensures a more controlled fall compared to attempting to catch or stop the client abruptly, which could lead to both the client and the nurse getting injured. Placing arms around the client may not provide enough support or control during the fall. Remaining upright or moving quickly in front of the client might not be practical or safe in this scenario.

2. A nurse is caring for an adolescent client who has full-thickness burns on his leg. The client expresses concern about his future. Which of the following is a therapeutic response by the nurse?

• A. “You’re concerned about what will happen when you leave the hospital?”
• B. “If you work hard on your physical therapy, you won’t need to worry.”
• C. “You shouldn’t worry about the future so you can concentrate on getting well.”
• D. “Why are you concerned even though everyone is here to help you?”

Correct answer: A

Rationale: The correct response is A, “You’re concerned about what will happen when you leave the hospital?” This response acknowledges the client's concerns about the future, validating their feelings and encouraging open communication. It shows empathy and allows the client to express their worries. Choice B minimizes the client's concerns by suggesting that they won't need to worry if they work hard on physical therapy, which may invalidate their emotions. Choice C dismisses the client's worry, implying that they should ignore their concerns to focus on getting well. Choice D uses a confrontational approach by questioning the client's concerns, which may discourage open communication and make the client feel defensive.

3. A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on clients who are confused. Which of the following instructions should the staff nurse include?

• A. Remove clocks from the client’s room
• B. Use full-length side rails on the client’s bed
• C. Check on the client frequently while they are in the restroom
• D. Encourage physical activity throughout the day to expend energy

Correct answer: D

Rationale: Encouraging physical activity throughout the day is an effective way to manage confusion in clients and reduce the need for restraints. Physical activity helps in expending energy, promoting circulation, and improving overall well-being. Removing clocks from the client’s room (choice A) may not directly address the issue of confusion or reduce the need for restraints. Using full-length side rails on the client’s bed (choice B) can actually increase the risk of entrapment and should be avoided. Checking on the client frequently while they are in the restroom (choice C) is important for monitoring safety but may not directly address the underlying issue of confusion and the need for restraints.

4. A client is expressing anger over his diagnosis of colorectal cancer. Which of the following actions should the nurse take?

• A. Discuss the risk factors for colorectal cancer.
• B. Focus teaching on addressing the client's anger and emotional response.
• C. Provide the client with emotional support and reassurance about his feelings.
• D. Reassure the client that this is an expected response to grief.

Correct answer: D

Rationale: The correct answer is D. During the anger stage of grief, it is essential for the nurse to reassure the client that anger is a normal reaction to a cancer diagnosis. This validation of the client's emotions can help in providing emotional support. Choice A is incorrect because discussing risk factors for colorectal cancer does not address the client's current emotional state. Choice B is incorrect because focusing teaching on the client's future management does not directly address the client's need for emotional support in the present. Choice C is incorrect because providing written information about loss and grief phases is not as immediately comforting as directly reassuring the client about his feelings of anger.

5. A client with brain cancer is transferring to hospice care. The client's son tells the nurse, 'I don’t know what to tell my dad if he asks how he is going to die.' Which of the following is an appropriate response by the nurse?

• A. “Let’s talk more about your dad’s condition.”
• B. “The social worker will help you answer those questions.”
• C. “I think that you should discuss this with the hospice nurse.”
• D. “Try to help your dad enjoy this time as much as he can.”

Correct answer: D

Rationale: Choosing option D, 'Try to help your dad enjoy this time as much as he can,' is the most appropriate response by the nurse. This response shows empathy and compassion towards the client and their family during this difficult transition. The focus on supporting the client in enjoying their remaining time reflects a holistic approach to care. Options A, B, and C are not the best responses in this situation. Option A could lead to unnecessary details that might be overwhelming for the family. Option B shifts the responsibility to the social worker without providing immediate support. Option C deflects the son's concerns to another healthcare professional when emotional support is needed.

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