Nursing Elites

1. An adolescent female reports being raped at a party where alcohol was served. The client admits to drinking alcohol before being raped by an acquaintance. The nurse should:

• A. inform the client that because she is underage, she is not at fault for attending a party where alcohol was served.
• B. ask the client if anyone witnessed the event because the client was intoxicated and might not remember it accurately.
• C. inform the client that it was not her fault, and support the client through the physical examination.
• D. question whether the woman had consensual sex and now just feels guilty.

Correct answer: C

Rationale: In cases of rape, it is crucial to provide support and reassurance to the victim. The nurse should inform the client that it was not her fault and offer support through the physical examination. Blaming the victim, as in choice A, is inappropriate and can be damaging to the client's well-being. Choice B is not the priority at this moment; the immediate focus should be on supporting the client. Choice D is victim-blaming and implies doubt about the client's report, which is harmful and not supportive. It is essential to create a safe and supportive environment for the client to facilitate healing and recovery.

2. What is the first exercise that should be performed by a client who had a mastectomy?

• A. Walking the hand up the wall
• B. Sweeping the floor
• C. Combing her hair
• D. Squeezing a ball

Correct answer: D

Rationale: The correct answer is D: Squeezing a ball. The first exercise that should be done by a client with a mastectomy is squeezing a ball. This helps in regaining strength and mobility in the affected area. Choices A, B, and C are incorrect as they are not typically the initial exercises recommended post-mastectomy. Walking the hand up the wall, sweeping the floor, and combing hair are activities that may be introduced later in the rehabilitation process.

3. A 50-milliliter (ml) bolus of normal saline fluid is ordered by the physician. The physician wants it to infuse in 30 minutes. The nurse should set the pump rate at:

• A. 100 ml per hour for one hour.
• B. 60 ml per hour for one-half hour
• C. 120 ml per hour for one hour.
• D. 50 ml per hour for one hour.

Correct answer: A

Rationale: To infuse a 50 ml bolus in 30 minutes, the rate should be calculated as follows: 50 ml / 30 min = 100 ml per hour. Therefore, the correct answer is to set the pump rate at 100 ml per hour for one hour. Choice A is the correct rate based on the calculation. Choices B, C, and D all provide incorrect rates that do not match the physician's order. Choice B would only deliver 30 ml in 30 minutes, not the ordered 50 ml. Choice C would deliver 120 ml in one hour, which is 20 ml more than ordered. Choice D would only provide 25 ml over 30 minutes, not the full 50 ml prescribed.

4. A woman asks, "How much alcohol can I safely drink while pregnant?"? The nurse's best response is:

• A. "The amount of alcohol that is safe during pregnancy is unknown."?
• B. "Consuming one or two beers or glasses of wine a day is considered safe for a healthy pregnant woman."?
• C. "Drinking three or more drinks on any given occasion is the only harmful type of drinking during pregnancy."?
• D. "You can have a drink to help you relax and get to sleep at night."?

Correct answer: A

Rationale: The correct answer is, "The amount of alcohol that is safe during pregnancy is unknown."? It is crucial for pregnant women to avoid alcohol as there is no known safe amount during pregnancy. Consuming any amount of alcohol can harm the developing fetus and increase the risk of fetal alcohol syndrome, a condition characterized by mental and physical abnormalities in infants. Choices B, C, and D are incorrect because they provide misleading information that can potentially harm the fetus. Pregnant women should abstain from alcohol to ensure the health and well-being of their baby.

5. A 32-year-old female frequently comes to her primary care provider with vague complaints of headache, abdominal pain, and trouble sleeping. In the past, the physician has dutifully prescribed medication, but little else. Which of the following comments by the nurse to the physician is appropriate?

• A. "Often women who are victims of domestic violence suffer vague symptoms such as abdominal pain."?
• B. "Often women become offended if asked about their safety in relationships."?
• C. "It is mandatory that all women be questioned about domestic violence."?
• D. "How would you feel to know that her partner is beating her and you didn't ask?"?

Correct answer: A

Rationale: The correct answer is, "Often women who are victims of domestic violence suffer vague symptoms such as abdominal pain."? There is a well-documented correlation between vague symptoms like abdominal pain and battered woman syndrome. It is crucial for healthcare providers to inquire about potential domestic violence when presented with such symptoms. Choice B is incorrect as studies show that women are not generally offended by appropriately phrased questions about their safety in relationships. While it is not mandatory to question all women about domestic violence, it is advisable to at least ask a screening question regarding safety. Choice D is inappropriate as it uses a shaming tactic, which is not constructive and may create a hostile work environment. It's important for healthcare professionals to approach sensitive topics like domestic violence with empathy and professionalism.

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