Nursing Elites

1. An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make?

• A. Ask, 'Tell me more about how your friends discourage you.'
• B. Say, 'Your friends should support you, not discourage you.'
• C. Respond, 'It sounds like your friends are not supportive.'
• D. Suggest, 'You need to focus on your treatment plans regardless of your friends.'

Correct answer: A

Rationale: The correct approach for the nurse is to ask the client to elaborate on how their friends discourage them. By doing so, the nurse shows empathy, encourages the client to express their feelings, and gains insight into the situation. This open-ended question can help the nurse understand the specific issues the client is facing and work towards finding solutions collaboratively. Choices B, C, and D do not effectively address the client's concerns or encourage further discussion. Choice B is directive and may come off as judgmental, choice C assumes the friends are not supportive without exploring further, and choice D dismisses the client's feelings and the impact of peer influence.

2. During assessment, what is a nurse monitoring when assessing body alignment?

• A. The relationship of one body part to another in different positions
• B. The coordination between musculoskeletal and nervous systems
• C. The force opposing movement direction
• D. The ability to move freely

Correct answer: A

Rationale: When a nurse assesses body alignment, they are observing the relationship of one body part to another in various positions. This involves evaluating the positioning of joints, tendons, ligaments, and muscles while a person is standing, sitting, or lying down. Choice B is incorrect because it refers more to the coordination between the musculoskeletal and nervous systems, which is not specifically related to body alignment assessment. Choice C is incorrect as it describes the force opposing movement rather than body alignment. Choice D is incorrect as it defines the ability to move freely, which is not directly related to monitoring body alignment.

3. The charge nurse on the unit observes that one of the staff nurses is not using proper hand washing techniques. Which is the most appropriate initial approach to correct the behavior?

• A. Remind the nurse that proper hand washing prevents infection
• B. Discuss what the nurse knows about proper hand hygiene
• C. Provide a review of the hand washing policy
• D. Refer the nurse to the infection control nurse

Correct answer: B

Rationale: The most appropriate initial approach to correct the behavior of improper hand washing by a staff nurse is to discuss what the nurse knows about proper hand hygiene. This approach helps in identifying any knowledge gaps the nurse may have and provides an opportunity to educate and correct the behavior. Option A is not the best choice as simply reminding the nurse about the importance of hand washing may not address the underlying issue of knowledge or technique. Option C, providing a review of the hand washing policy, may be necessary but is not the most immediate step to take. Option D, referring the nurse to the infection control nurse, is premature and may not be necessary if the issue can be resolved through education and communication first.

4. A client reports having insomnia. Which of the following interventions is appropriate for the nurse to recommend?

• A. Exercise 1 hour before bedtime.
• B. Eat a light carbohydrate snack before bedtime.
• C. Drink a cup of hot cocoa before bedtime.
• D. Take a 30-minute nap daily.

Correct answer: B

Rationale: Eating a light carbohydrate snack before bedtime is a suitable intervention for insomnia because it can help stabilize blood sugar levels and promote sleep. Exercising close to bedtime may actually disrupt sleep patterns due to increased alertness and body temperature. Drinking hot cocoa before bedtime, which contains caffeine, may interfere with falling asleep. Taking a nap during the day can make it harder to fall asleep at night and may worsen insomnia. Therefore, the best recommendation among the choices provided is to eat a light carbohydrate snack before bedtime.

5. A client is 6 hours postoperative following abdominal surgery and is having difficulty voiding. Which of the following actions should the nurse take?

• A. Allow the client to hear running water while attempting to void
• B. Provide the client with a bedpan while sitting upright
• C. Insert an indwelling urinary catheter and connect it to gravity drainage
• D. Encourage the client to limit fluid intake

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to allow the client to hear running water while attempting to void. This can help stimulate the urge to urinate in a non-invasive way, promoting natural voiding. Providing a bedpan while sitting upright is also a suitable approach to facilitate voiding by encouraging a more natural position. Inserting an indwelling urinary catheter should be a last resort due to infection risks and discomfort associated with catheterization. Encouraging the client to limit fluid intake is not appropriate as hydration is crucial for overall health and can aid in promoting voiding. Therefore, the best initial intervention to promote voiding in this scenario is to allow the client to hear running water.

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