Nursing Elites

1. A client is being taught about the use of hypnosis during labor. Which of the following statements is appropriate?

• A. Hypnosis focuses on biofeedback as a relaxation technique
• B. Hypnosis promotes increased control of pain perception during contractions
• C. Hypnosis uses therapeutic touch to reduce anxiety during labor
• D. Hypnosis provides instruction to minimize pain

Correct answer: B

Rationale: The correct answer is B because hypnosis during labor aims to increase control over pain perception, helping manage labor pain without the need for medication. Choice A is incorrect as hypnosis doesn't primarily focus on biofeedback. Choice C is incorrect because hypnosis doesn't rely on therapeutic touch. Choice D is incorrect because hypnosis doesn't just provide instructions to minimize pain but rather helps individuals gain control over their pain perception.

2. A client is 24 hours postoperative following a right-sided mastectomy. Which of the following interventions should the nurse include in the plan of care?

• A. Place the client in the supine position.
• B. Encourage the client to lift objects with the right arm.
• C. Measure the client's blood pressure on the right arm.
• D. Elevate the client's right arm on a pillow.

Correct answer: D

Rationale: Elevating the client's right arm on a pillow is essential post-mastectomy to reduce swelling and promote circulation. Placing the client in the supine position may not be comfortable or ideal after a mastectomy. Encouraging the client to lift objects with the right arm can strain the surgical site and hinder healing. Measuring the client's blood pressure on the right arm should be avoided to prevent disruption to the area and inaccurate readings.

3. A healthcare provider is educating a client with type 2 diabetes mellitus about managing blood glucose levels. Which of the following statements by the client indicates a need for further teaching?

• A. I will monitor my blood glucose levels every morning.
• B. I will stop taking my insulin if my blood glucose level is below 200 mg/dL.
• C. I will take my insulin as prescribed, even if I am feeling well.
• D. I will eat more simple carbohydrates if my blood glucose level is low.

Correct answer: D

Rationale: The correct answer is D because consuming more simple carbohydrates when blood glucose levels are low can cause a rapid spike in blood sugar levels, leading to potential complications. Clients with type 2 diabetes should eat complex carbohydrates or foods that help stabilize blood sugar levels when experiencing hypoglycemia. Choices A, B, and C demonstrate understanding of monitoring blood glucose levels regularly, not stopping insulin without consulting a healthcare provider, and adhering to insulin therapy even when feeling well, which are all appropriate actions for managing diabetes.

4. A nurse is planning care for a client who is postoperative following a bowel resection. Which of the following interventions should the nurse include?

• A. Encourage the client to drink adequate fluids daily.
• B. Administer pain medication as needed.
• C. Instruct the client to splint the incision with a pillow.
• D. Encourage the client to eat a balanced diet.

Correct answer: C

Rationale: The correct intervention for a client post-bowel resection is to instruct the client to splint the incision with a pillow. This technique helps prevent dehiscence, which is the separation of wound edges, and reduces pain when coughing or moving. Splinting supports the incision site, decreasing tension on the wound. Encouraging the client to drink adequate fluids promotes hydration and aids in recovery, but a specific volume like 1,000 mL mentioned in choice A is not essential. Pain medication should be administered as needed for adequate pain control, not necessarily before every meal. Instructing the client to eat a balanced diet, including adequate protein, is crucial for wound healing and overall recovery, rather than limiting protein intake.

5. A client is experiencing mild anxiety. Which of the following findings should the nurse expect?

• A. Feelings of dread
• B. Heightened perceptual field
• C. Rapid speech
• D. Purposeless activity

Correct answer: B

Rationale: In clients experiencing mild anxiety, a heightened perceptual field is a common finding. This means that the individual may be more alert and observant of their surroundings, sometimes to the point of being hyper-aware. Choices A, C, and D are less likely to be associated with mild anxiety. Feelings of dread (Choice A) are more commonly seen in moderate to severe anxiety. Rapid speech (Choice C) may be observed in some cases of anxiety, but it is not a specific hallmark of mild anxiety. Purposeless activity (Choice D) is more indicative of severe anxiety or other mental health conditions.

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