Nursing Elites

1. A healthcare professional uses a head-to-toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking did the healthcare professional demonstrate?

• A. Confidence
• B. Perseverance
• C. Integrity
• D. Discipline

Correct answer: D

Rationale: The correct answer is 'Discipline.' In this scenario, discipline is exemplified by following a structured and comprehensive assessment process, as seen in the head-to-toe approach. Confidence (choice A) relates to self-assurance and belief in one's abilities, which is not the primary critical thinking demonstrated in this situation. Perseverance (choice B) is the persistence in achieving goals despite challenges, not directly related to the systematic assessment process. Integrity (choice C) pertains to honesty and ethical behavior, which are important traits but not the critical thinking skill exemplified by the structured assessment process shown in the head-to-toe approach.

2. A client who requires maximal support is being taught how to use a two-wheeled walker by a nurse. Which of the following actions by the client indicates an understanding of the teaching?

• A. The client moves the walker ahead 25.4 cm with each step
• B. The client picks up the walker with each step
• C. The client stands with elbows slightly bent while holding the walker
• D. The client stoops slightly forward when moving the walker

Correct answer: C

Rationale: The correct answer is C. When using a two-wheeled walker, the client should stand with elbows slightly bent to maintain balance and stability. This position helps distribute weight effectively and promotes proper use of the walker. Choices A, B, and D are incorrect. Choice A does not demonstrate proper posture while using the walker. Choice B of picking up the walker with each step is not the correct technique and can lead to instability. Choice D of stooping slightly forward is also incorrect as it can affect balance and posture negatively.

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

• A. Reassure the client that this is an expected response to grief.
• B. Ignore the client’s anger and continue with the plan of care.
• C. Tell the client that anger is not going to help his situation.
• D. Encourage the client to express his anger.

Correct answer: A

Rationale: When a client is expressing anger about a diagnosis, it is essential for the nurse to validate the client's feelings. Choice A is correct because reassuring the client that anger is an expected response to grief acknowledges the client's emotions and encourages expression, fostering a therapeutic relationship. This validation helps the client feel understood and supported during a challenging time. Choice B is incorrect as ignoring the client's anger can lead to feelings of neglect and hinder effective communication, which is crucial for providing holistic care. Choice C is inappropriate because telling the client that anger is not helpful dismisses the client's emotions and can further escalate the situation, potentially damaging the nurse-client relationship. Choice D is not the best option as it does not involve acknowledging the client's feelings or providing support and validation, which are vital in promoting emotional well-being and trust between the client and the nurse.

4. A client who is confused and pulling at the tubing of her IV is being cared for by a nurse. Which of the following actions should the nurse take before requesting a prescription for restraints from the provider?

• A. Place the client in a room away from the nurses’ station.
• B. Limit the client’s visitors.
• C. Give the client washcloths to fold.
• D. Close the door of the client’s room.

Correct answer: C

Rationale: Providing the client with washcloths to fold is a non-restrictive intervention that can help distract and engage the client, potentially reducing the need for restraints. This action promotes a therapeutic and calming environment for the confused client. Placing the client in a room away from the nurses’ station (Choice A) may not address the underlying issue of confusion and agitation. Limiting the client’s visitors (Choice B) may not directly assist in managing the client's behavior. Closing the door of the client’s room (Choice D) does not actively engage the client in a therapeutic intervention to address the behavior.

5. A client with Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?

• A. Comatose, breathing unlabored
• B. Glasgow Coma Scale 8, respirations regular
• C. Appears to be sleeping, vital signs stable
• D. Glasgow Coma Scale 13, no ventilator required

Correct answer: B

Rationale: A client with Guillain-Barre syndrome in a non-responsive state with stable vital signs and independent breathing would most accurately be described by a Glasgow Coma Scale of 8 with regular respirations. Choice A is incorrect as 'comatose' implies a deeper level of unconsciousness than described in the scenario. Choice C is incorrect as 'appears to be sleeping' is not an accurate description of a non-responsive state. Choice D is incorrect as a Glasgow Coma Scale of 13 indicates a higher level of consciousness than stated in the scenario.

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