Nursing Elites

1. An older adult who recently began self-administration of insulin calls the nurse daily to review the steps that should be taken when giving an injection. The nurse has assessed the client's skills during two previous office visits and knows that the client is capable of giving the daily injection. Which response by the nurse is likely to be most helpful in encouraging the client to assume total responsibility for the daily injections?

• A. I know you are capable of giving yourself the insulin.
• B. Giving yourself the injection seems to make you nervous.
• C. When I watched you give yourself the injection, you did it correctly.
• D. Tell me what you want me to do to help you give yourself the injection at home.

Correct answer: C

Rationale: Choice C is the correct answer because focusing on the client's demonstrated ability to self-administer the injection is likely to reinforce his level of competence without sounding punitive. By acknowledging the client's correct performance during the self-injection, the nurse can boost the client's confidence, encouraging him to assume total responsibility for the daily injections. Choices A, B, and D do not directly highlight the client's competence in self-administration, which may not be as effective in promoting independent self-care.

2. When assisting an older client who can stand but not ambulate from the bed to a chair, what is the best action for the nurse to implement?

• A. Use a mechanical lift to transfer the client from the bed to a chair.
• B. Place a roller board under the client who is sitting on the side of the bed and slide the client to the chair.
• C. Lift the client out of bed to the chair with another staff member using a coordinated effort on the count of three.
• D. Place a transfer belt around the client, assist the client to stand, and pivot to a chair that is placed at a right angle to the bed.

Correct answer: D

Rationale: The best action for the nurse when assisting an older client who can stand but not ambulate from the bed to a chair is to use a transfer belt. Placing a transfer belt around the client, assisting the client to stand, and pivoting to a chair that is placed at a right angle to the bed allows for a safe and controlled transfer. This method promotes patient independence while ensuring safety during the transfer process. Choices A, B, and C are incorrect because using a mechanical lift may not be necessary for a client who can stand, using a roller board may not provide enough stability, and lifting the client with the help of another staff member may not be the safest option for the client's independence and safety.

3. The client has removed the covering from an ice pack applied to his knee. What action should the nurse take first?

• A. Observe the appearance of the skin under the ice pack.
• B. Instruct the client regarding the importance of the covering.
• C. Reapply the covering after filling it with fresh ice.
• D. Ask the client how long the ice pack was applied to the skin.

Correct answer: A

Rationale: The primary action for the nurse is to assess the skin under the ice pack to check for any potential thermal injury. This assessment is crucial to ensure the client's safety. Once the skin assessment is done and no harm is found, the nurse can proceed with other necessary actions such as providing instructions to the client or replacing the covering with fresh ice.

4. A high school senior is complaining of a persistent cough and admits to smoking 10 to 15 cigarettes daily for the past year. He is convinced that he is hopelessly addicted to tobacco since he tried unsuccessfully to quit smoking last week. Which intervention is best for the nurse to implement?

• A. Encourage the student to associate with non-smokers only while attempting to stop smoking.
• B. Tell the student that he is still young and should continue trying various smoking cessation methods.
• C. Describe cigarette smoking as a habit that requires a strong will to overcome its addictiveness.
• D. Provide the student with the latest research data describing the long-term effects of tobacco use.

Correct answer: A

Rationale: Adolescents are particularly influenced by peers, so associating with non-smokers may help the student quit smoking. By being surrounded by non-smokers, the student is less likely to feel pressured to smoke and may be encouraged to adopt healthier behaviors. This intervention leverages the power of social influence to support smoking cessation efforts and create a more conducive environment for the student to quit smoking. Choices B, C, and D do not address the social aspect of smoking behavior and the influence of peers on smoking habits, making them less effective interventions in this case.

5. A client who has a body mass index (BMI) of 30 is requesting information on the initial approach to a weight loss plan. Which action should the nurse recommend first?

• A. Plan low carbohydrate and high protein meals
• B. Engage in strenuous activity for an hour daily
• C. Keep a record of food and drinks consumed daily
• D. Participate in a group exercise class 3 times a week

Correct answer: C

Rationale: Keeping a food diary is a good first step to understand eating habits before making any dietary or activity changes.

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