Nursing Elites

1. A successful resolution of the nursing diagnosis Negative Self-Concept (related to unrealistic self-expectations) is when the client can:

• A. report a positive self-concept.
• B. identify negative thoughts.
• C. recognize positive thoughts.
• D. give one positive cue with each negative cue

Correct answer: A

Rationale: The correct answer is to 'report a positive self-concept.' The problem statement is Negative Self-Concept, so the goal is for the client to achieve a positive self-concept. This involves helping the client recognize their worth and strengths. Choices B, C, and D do not directly address the resolution of Negative Self-Concept. Identifying negative thoughts (B) is a step towards improvement but does not represent a successful resolution. Recognizing positive thoughts (C) is positive but not the primary goal in addressing Negative Self-Concept. 'Give one positive cue with each negative cue' (D) is not as comprehensive as achieving an overall positive self-concept.

2. A 57-year-old woman is recently widowed. She states, "I will never be able to learn how to manage the finances. My husband did all of that."? Select the nurse's response that could help raise the client's self-esteem.

• A. "You feel inadequate because you have never learned to balance a checkbook."?
• B. "You should have insisted your husband teach you about the finances."?
• C. "You are strong and will learn how to manage your finances after a while."?
• D. "I believe in your strength to learn how to manage your finances in time."?

Correct answer: C

Rationale: The nurse should aim to boost the client's self-esteem by providing positive reinforcement. By stating, "You are strong and will learn how to manage your finances after a while,"? the nurse acknowledges the client's strength and capability, encouraging her to believe in herself. Choice A is incorrect as it focuses on the client's inadequacy rather than empowering her. Choice B places unnecessary blame on the client for not taking action in the past. Choice D, though positive, slightly alters the nurse's original phrase, making choice C the most appropriate response to uplift the client's self-esteem.

3. How can the nurse best communicate to a client that he or she has been listening?

• A. restating the main feeling or thought the client has expressed
• B. making a judgment about the client's problem
• C. offering a leading question such as, 'And then what happened?'
• D. saying, 'I understand what you're saying.'

Correct answer: A

Rationale: The best way for the nurse to communicate to a client that he or she has been listening is by restating the main feeling or thought the client has expressed. Restating helps the client validate the nurse's understanding of the communication, demonstrating active listening skills. Making judgments about the client's problem, as suggested in Choice B, can hinder effective communication by introducing bias and potential misinterpretation. Offering a leading question like in Choice C is not ideal for confirming understanding; it rather seeks more information. Choice D, simply saying 'I understand what you're saying,' may not convey active listening as effectively as restating the client's main feelings or thoughts, as it lacks the validation component present in restating.

4. A client with cancer develops xerostomia. The nurse can help alleviate the discomfort associated with xerostomia by:

• A. Offering hard candy
• B. Administering analgesic medications
• C. Splinting swollen joints
• D. Providing saliva substitute

Correct answer: D

Rationale: Xerostomia is dry mouth, a common side effect in cancer patients. Providing a saliva substitute helps alleviate the discomfort associated with dry mouth by moistening the oral mucosa. Offering hard candy, as mentioned in choice A, can worsen xerostomia by increasing sugar content and potentially causing irritation. Administering analgesic medications, as in choice B, is not directly related to treating dry mouth. Splinting swollen joints, as in choice C, is irrelevant to xerostomia, which primarily affects the oral cavity.

5. The client is receiving heparin for thrombophlebitis of the left lower extremity. Which of the following drugs reverses the effects of heparin?

• A. Cyanocobalamin
• B. Protamine sulfate
• C. Streptokinase
• D. Sodium warfarin

Correct answer: B

Rationale: The correct answer is Protamine sulfate. Protamine sulfate is the antidote for heparin, as it reverses its effects. Cyanocobalamin is a form of Vitamin B12 and is not used to reverse heparin effects. Streptokinase is a thrombolytic agent that is used to dissolve blood clots, not to reverse heparin effects. Sodium warfarin is an anticoagulant, but it is not the antidote for heparin. Therefore, answers A, C, and D are incorrect as they do not reverse the effects of heparin.

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