Nursing Elites

1. In a brief treatment program for a client who was raped, what is a realistic short-term goal?

• A. Identify all psychosocial problems.
• B. Eliminate the client's enticing behaviors.
• C. Resolve feelings of trauma and fear.
• D. Verbalize feelings about the event.

Correct answer: D

Rationale: In this scenario, a realistic short-term goal for the client who was raped and starting a brief treatment program is to verbalize feelings about the event. This goal promotes the expression of emotions, which is crucial in the healing process. Identifying all psychosocial problems is too broad and not typically achievable in a brief treatment program. Eliminating the client's enticing behaviors is not a suitable short-term goal as the focus should be on emotional recovery. While resolving feelings of trauma and fear is important, verbalizing feelings about the event is a more specific and achievable goal in the short term.

2. In the United States, several definitions of death are currently being used. The definition that uses apnea testing and pupillary responses to light is termed:

• A. whole brain death.
• B. heart-lung death.
• C. circulatory death.
• D. higher brain death.

Correct answer: A

Rationale: The correct answer is 'whole brain death.' Most protocols for determining whole brain death require two separate clinical examinations, including the induction of painful stimuli, pupillary responses to light, oculovestibular testing, and apnea testing. This comprehensive approach ensures that all functions of the brain, including the brainstem, are evaluated to confirm the absence of brain function. Choices B and D are incorrect as they do not reflect the specific tests required for determining whole brain death. Choice C, 'circulatory death,' does not involve the evaluation of brain function and is not a current definition of death in the United States.

3. Spirituality affects a client's life in all of the following areas except:

• A. nutritional intake.
• B. ability to handle stress.
• C. sexual expression.
• D. genetic makeup.

Correct answer: D

Rationale: Spirituality is a belief in or relationship with some higher power, creative force, divine being, or infinite source of energy. It can influence areas such as nutritional intake, the ability to handle stress, and sexual expression by providing comfort, guidance, and a sense of purpose. However, spirituality does not have any effect on genetic makeup, as genetics are determined by biological inheritance and not influenced by spiritual beliefs. Choices A, B, and C are directly influenced by an individual's spiritual beliefs and practices, impacting their overall well-being and behavior.

4. A 6-month-old client is admitted with possible intussusception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?

• A. "Tell me about his pain."?
• B. "What does his vomit look like?"?
• C. "Describe his usual diet."?
• D. "Have you noticed changes in his abdominal size?"?

Correct answer: C

Rationale: The least helpful question in obtaining information regarding intussusception is "Describe his usual diet."? This question is least relevant to the specific symptoms and presentation of intussusception. Choices A, B, and D are more directly related to symptoms commonly associated with intussusception and can provide important diagnostic clues. Asking about pain, vomit appearance, and changes in abdominal size can help in assessing the severity and progression of the condition, making them more crucial questions to ask in this scenario. Pain is a cardinal symptom of intussusception, changes in vomit appearance may indicate gastrointestinal issues, and alterations in abdominal size can signify the presence of a mass or obstruction, all of which are pertinent in diagnosing and managing intussusception.

5. A client with cancer is to undergo an intravenous pyelogram. The nurse should:

• A. Ensure adequate fluid intake 24 hours before the procedure
• B. Ask the client to void immediately before the study
• C. Administer medication that affects the central nervous system as prescribed
• D. Position the client appropriately for the procedure

Correct answer: B

Rationale: The correct answer is to ask the client to void immediately before the study. For an intravenous pyelogram, the client may have orders for laxatives or enemas, so ensuring the client voids before the test is important to prevent obscuring visualization of the kidney, ureters, and bladder. Choice A is incorrect because there is no need to force fluids before the procedure. Choice C is incorrect as medications affecting the central nervous system should not be held unless specified by the healthcare provider. Choice D is incorrect as covering the reproductive organs with an x-ray shield is not necessary for an intravenous pyelogram.

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