Nursing Elites

1. A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

• A. Elevate the head of the bed no more than 45 degrees
• B. Apply cornstarch to keep sensitive skin areas dry
• C. Massage the skin over the client's bony prominences
• D. Use a transfer device to lift the client up in bed

Correct answer: D

Rationale: The correct answer is to use a transfer device to lift the client up in bed. This intervention helps reduce friction and the risk of skin breakdown, aiding in the prevention of pressure ulcers. Elevating the head of the bed no more than 45 degrees can help with respiratory issues but does not directly address skin integrity. Applying cornstarch may lead to further skin irritation. Massaging over bony prominences can increase the risk of skin damage rather than maintaining skin integrity.

2. A parent of a child who is terminally ill tells a nurse that she wants to take her child home. Which of the following responses should the nurse make?

• A. Your provider will be here later today.
• B. I can give you information on what that would involve.
• C. I understand how you feel. I felt the same way when my sister was terminally ill.
• D. I think you should speak with social services about your request.

Correct answer: B

Rationale: The nurse should offer to explain the process of taking the child home and provide resources for the parent's decision. Choice B is the best response as it shows willingness to support the parent by offering information on what taking the child home would involve. Choices A, C, and D do not directly address the parent's request or provide the necessary information and support needed in this situation.

3. A nurse is evaluating care of an immobilized patient. Which action will the nurse take?

• A. Involve primarily the patient's family and healthcare team to determine goal achievement.
• B. Focus on whether the interdisciplinary team is satisfied with the care.
• C. Use objective data solely to determine whether interventions have been successful.
• D. Compare the patient's actual outcomes with the outcomes in the care plan.

Correct answer: D

Rationale: The correct answer is D because comparing the patient's actual outcomes with the outcomes in the care plan is essential in evaluating the effectiveness of care provided to an immobilized patient. This comparison helps in identifying any disparities between the planned care and the actual care received, allowing the nurse to make necessary adjustments to improve patient outcomes. Choices A, B, and C are incorrect because while involving the patient's family and healthcare team, ensuring interdisciplinary team satisfaction, and using objective data are important aspects of patient care, they do not directly address the specific action needed to evaluate care for an immobilized patient.

4. Which of the following is a recommended approach for handling aggressive behavior in a mental health setting?

• A. Encourage the client to express their feelings through physical activity
• B. Avoid making eye contact to prevent escalation
• C. Use pharmacological interventions immediately
• D. Maintain eye contact, offer clear choices, and set boundaries

Correct answer: D

Rationale: The recommended approach for handling aggressive behavior in a mental health setting is to maintain eye contact, offer clear choices, and set boundaries. This approach can help de-escalate the situation by establishing communication and structure. Choice A is incorrect as encouraging physical activity may not be suitable during an aggressive episode. Choice B is incorrect because avoiding eye contact can hinder communication and resolution. Choice C is also incorrect as pharmacological interventions should not be the immediate go-to method for managing aggression unless absolutely necessary.

5. A client undergoing chemotherapy expresses concern about hair loss. What should the nurse suggest?

• A. Encourage the client to cut their hair short before chemotherapy.
• B. Provide resources for wigs or hairpieces.
• C. Assure the client that hair loss will be minimal.
• D. Offer the client medication to reduce the chances of hair loss.

Correct answer: B

Rationale: The correct answer is B: Providing wigs and other coping resources helps clients manage the emotional effects of chemotherapy-related hair loss. Encouraging the client to cut their hair short before chemotherapy (Choice A) is not necessary as hair loss may still occur. Assuring the client that hair loss will be minimal (Choice C) may provide false hope as hair loss is a common side effect of chemotherapy. Offering medication to reduce hair loss (Choice D) is not a typical approach as chemotherapy-related hair loss is often an expected side effect that cannot be entirely prevented with medication.

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