Nursing Elites

1. An adult who had been abused as a child is discussing the group therapy program. Which statement indicates that the client has gained insight?

• A. "I think I was a lonely child because I could not tell anyone about my abuse."?
• B. "I am now aware of how deep-seated my anger is. Before, I did not realize I was angry."?
• C. "The program has given me the courage to tell my mother how I felt about her role in my hurt."?
• D. "There are so many people just like me, who are just normal people that had bad things happen to them."?

Correct answer: B

Rationale: The correct answer demonstrates insight gained by the client regarding their emotional state. Recognizing deep-seated anger that was previously unrecognized indicates progress in understanding their emotions and the impact of past abuse. Choice A reflects a sense of loneliness due to an inability to share about the abuse, which does not directly address emotional insight. Choice C shows progress in addressing relationships but does not specifically relate to emotional awareness. Choice D acknowledges shared experiences but does not reflect personal emotional growth or insight.

2. Six hours after birth, the infant is found to have an area of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as:

• A. A cephalohematoma
• B. Molding
• C. Subdural hematoma
• D. Caput succedaneum

Correct answer: A

Rationale: The correct answer is A, a cephalohematoma. A cephalohematoma is an area of bleeding outside the cranium but beneath the periosteum, typically not crossing the suture line. Answer B, molding, is the overlapping of the bones of the cranium and does not involve bleeding, making it an incorrect choice. Answer C, a subdural hematoma, involves intracranial bleeding and is typically diagnosed through imaging studies like a CAT scan or x-ray. Answer D, caput succedaneum, is characterized by edema that crosses the suture line, unlike the described swelling in this case.

3. Which intervention should the nurse take first to assist a woman who states that she feels incompetent as the mother of a teenage daughter?

• A. Recommend that she discipline her daughter more strictly and consistently.
• B. Make a list of things she can do to help improve her husband.
• C. Assist the mother to identify what she believes is preventing her success and what she can do to improve.
• D. Explore with the mother what the daughter can do to improve her behavior.

Correct answer: C

Rationale: The priority intervention for a mother who feels incompetent in parenting a teenage daughter is to assist her in identifying the factors contributing to her feelings of inadequacy and help her develop better coping and mothering skills. This approach focuses on addressing the mother's emotional needs and empowering her to improve her situation. Option A is incorrect as it focuses on the daughter's discipline, which may not be the root cause of the mother's feelings. Option B is irrelevant as it focuses on improving her husband, not her parenting skills. Option D is incorrect as it shifts the focus solely to the daughter's behavior, neglecting the mother's emotional needs and self-improvement.

4. A client reports that someone is in the room and trying to kill him. The nurse's best response is:

• A. "No one is in your room. Let's get you more medicine."?
• B. "I do not see anyone, but you seem to be very frightened."?
• C. "No one can hurt you here."?
• D. "Just tell the person to go away."?

Correct answer: B

Rationale: When a client reports hallucinations or delusions, it is crucial to respond in a non-confrontational and empathetic manner. Choice B acknowledges the client's fear without confirming the delusion, showing understanding, and providing reassurance. This response validates the client's feelings without reinforcing the false belief. The other responses in choices A, C, and D dismiss the client's feelings or perceptions, which can escalate the situation and harm the therapeutic relationship.

5. A client reports hearing voices. What should the nurse do next?

• A. Touch the client to help him return to reality.
• B. Leave the client alone until reality returns.
• C. Ask the client to describe what is happening.
• D. Tell the client there are no voices.

Correct answer: C

Rationale: When a client reports hearing voices, it might indicate hallucinations. It is essential for the nurse to ask the client to describe what is happening to gain a better understanding of the hallucinations. This approach helps in assessing the severity and content of the hallucinations, which can guide further interventions. Touching the client without consent can be intrusive and may escalate the situation, violating the client's personal space. Leaving the client alone may not address the underlying issue of hallucinations and can lead to potential risks if the client is distressed. Telling the client there are no voices denies their experience, invalidates their feelings, and can result in mistrust between the client and the nurse.

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