Nursing Elites

1. When a patient refuses to believe a terminal diagnosis, they are exhibiting:

• A. Regression
• B. Mourning
• C. Denial
• D. Rationalization

Correct answer: C

Rationale: Denial is a defense mechanism where a patient rejects a reality that is too painful or difficult to accept. In the context of a terminal diagnosis, the patient may refuse to believe it in order to avoid facing the harsh truth. Regression (choice A) involves reverting to earlier, more childlike behaviors and is not applicable in this scenario. Mourning (choice B) is the process of grieving a loss, which typically occurs after acceptance of the diagnosis. Rationalization (choice D) is creating logical explanations to justify unacceptable behaviors, which is not the case when a patient denies a terminal diagnosis.

2. A nurse is preparing to insert a small-bore nasogastric feeding tube for a client's enteral feedings. In which method does the nurse measure the correct length of the tube?

• A. From the tip of the nose to the xiphoid process
• B. From the tip of the nose to the earlobe to the xiphoid process
• C. From the earlobe to the xiphoid process
• D. From the tip of the nose to the earlobe to the umbilicus

Correct answer: B

Rationale: When preparing to insert a nasogastric tube, the nurse must measure the correct length to ensure that the end of the tube will be in the correct position in the stomach. The accurate method to measure the length is from the tip of the nose to the earlobe to the xiphoid process. This length ensures that the end of the tube reaches the stomach, avoiding placement in the small intestine or esophagus. Choice A is incorrect as it does not include the earlobe, which is essential for accurate measurement. Choice C is incorrect because measuring from the earlobe alone does not provide the correct length for positioning in the stomach. Choice D is incorrect as it includes the umbilicus, which is not the appropriate landmark for measuring the length of a nasogastric tube intended for stomach placement.

3. An Asian-American woman is experiencing diarrhea, which is believed to be "cold"? or "yin."? What should the nurse recognize that the woman may likely try to treat it?

• A. Foods that are "hot"? or "yang"?
• B. Readings and Eastern medicine meditations
• C. High doses of medicines believed to be "cold"?
• D. No treatment because diarrhea is an expected part of life.

Correct answer: A

Rationale: In this scenario, the Asian-American woman is believed to be experiencing diarrhea due to a "cold"? or "yin"? imbalance. According to the yin/yang theory, yang represents heat and yin represents cold. Therefore, to balance the cold nature of the diarrhea, the woman may try to treat it by consuming foods that are considered "hot"? or "yang"?. This aligns with the concept that cold foods are eaten with a hot illness, and hot foods are eaten with a cold illness. Choices B, C, and D do not align with the yin/yang theory and are not relevant to addressing the imbalance associated with the cold nature of the diarrhea.

4. Your patient who had AIDS/HIV has just died. Should you still use standard precautions as you provide post-mortem care?

• A. Yes, because the virus is still transmissible
• B. Yes, because respect must still be maintained
• C. No, because the virus is no longer transmissible
• D. No, because it is disrespectful

Correct answer: A

Rationale: Yes, you should still use standard precautions even after an HIV/AIDS patient has died. The virus can remain infectious after death, and healthcare workers need to protect themselves from potential exposure. Choice B is incorrect because while respect is important, the primary reason for using standard precautions is to prevent transmission of infectious diseases. Choice C is incorrect as the virus can still be transmissible even after the patient's death. Choice D is incorrect as using standard precautions is a matter of infection control, not a question of respect.

5. Which of these is a correctly stated outcome goal written by the nurse?

• A. The client will walk 2 miles daily by March 19
• B. The client will understand how to give insulin by discharge
• C. The client will regain their former state of health by April 1
• D. The client achieve desired mobility by May 7

Correct answer: A

Rationale: Outcome goals should be SMART, i.e., Specific, Measurable, Appropriate, Realistic, and Timely. Option A is the only outcome that has a specific behavior (walks daily), with measurable performance criteria (2 miles), and a time estimate for goal attainment (by March 19). Option B lacks specificity in terms of what 'understand how to give insulin' entails, and the timeline is vague ('by discharge'). Option C is not measurable or specific about what 'regain their former state of health' means. Option D does not provide a specific behavior or measurable criteria for 'desired mobility,' and the timeline is the only element that is time-bound.

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