Nursing Elites

1. A woman presents with bruises on her face and back in various stages of healing. She states, 'sometimes he just gets so angry.' Which of the following statements is most appropriate as a response from the nurse?

• A. Do you mean your boyfriend?
• B. Do you mean your boyfriend?
• C. No one will ever hurt you again.
• D. Tell me more about what happens when he gets angry.

Correct answer: D

Rationale: The most appropriate response from the nurse is to gather more information by asking the client to elaborate on what occurs when the individual in question gets angry. It is essential for the nurse to understand the situation better before taking any action or making assumptions. Option A and B are repetitive and do not encourage further exploration of the situation. Option C offers a false promise and reassurance that the nurse cannot guarantee, which may not be helpful in addressing the client's needs.

2. A client with schizophrenia seems to stop focusing during a conversation with a nurse and begins looking at the ceiling and talking to themselves. Which of the following actions should the nurse take?

• A. Stop the interview at this point and resume later when the client is better able to concentrate
• B. Ask the client, 'Are you seeing something on the ceiling?'
• C. Tell the client, 'You seem to be looking at something on the ceiling. I see something there, too.'
• D. Continue the interview without commenting on the client's behavior

Correct answer: B

Rationale: When a client with schizophrenia experiences a break in reality like staring at the ceiling and talking to themselves, the nurse should ask directly about the hallucination, as stated in choice B. By doing so, the nurse can assess the situation, identify the client's needs, and evaluate any potential risk for injury. Choices A, C, and D are incorrect. Stopping the interview (choice A) may not address the immediate concern of the hallucination. Providing false reassurance (choice C) or ignoring the behavior (choice D) does not actively address the client's altered perception of reality.

3. Asepsis is defined as ________________.

• A. the absence of all microorganisms
• B. the absence of disease-causing germs
• C. a urinary infection
• D. a pathogenic infection

Correct answer: B

Rationale: Asepsis is defined as the absence of disease-causing germs. It is surgical asepsis that is defined as the absence of all microorganisms, including spores. A pathogenic infection is an invasion of the body by a pathogen, or disease-causing germ, and a urinary infection is only one type of infection.

4. A healthcare professional is preparing to insert an indwelling catheter in a female client. Which of the following positions of the client is most appropriate for this procedure?

• A. Lithotomy position
• B. Prone position
• C. Dorsal recumbent position
• D. High Fowler's position

Correct answer: C

Rationale: When preparing to insert an indwelling catheter for a female client, the most appropriate position is the dorsal recumbent position. In this position, the client lies on their back with knees bent. This position allows for easy access to the urethral area for catheter insertion. The lithotomy position, with legs elevated and spread apart, is more invasive and typically used for gynecological exams. The prone position, lying face down, is not suitable for catheter insertion. High Fowler's position, sitting upright at a 90-degree angle, is not ideal for catheter insertion as it does not provide proper access to the perineal area.

5. A nursing student is teaching a patient and family about epilepsy prior to the patient's discharge. For which statement should you intervene?

• A. "You should avoid consumption of all forms of alcohol."?
• B. "Wear your medical alert bracelet at all times."?
• C. "Protect your loved one's airway during a seizure."?
• D. "It's important to consult with your physician before taking over-the-counter medications."?

Correct answer: D

Rationale: The correct answer is, "It's important to consult with your physician before taking over-the-counter medications."? Patients with epilepsy should not take over-the-counter medications without medical advice due to potential interactions with antiepileptic drugs or triggering seizures. Choices A, B, and C are all appropriate statements for a patient with epilepsy, focusing on alcohol avoidance, wearing a medical alert bracelet, and airway protection during a seizure, respectively. Choice D is incorrect because patients with epilepsy need to be cautious about medications due to possible interactions or adverse effects, so consulting with a physician is crucial before taking over-the-counter medications.

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