Nursing Elites

1. Based on the nursing diagnosis of risk for infection, which intervention is best for the nurse to implement when providing care for an older incontinent client?

• A. Maintain standard precautions.
• B. Initiate contact isolation measures.
• C. Insert an indwelling urinary catheter.
• D. Instruct the client in the use of adult diapers.

Correct answer: A

Rationale: The correct intervention for a nursing diagnosis of risk for infection in an older incontinent client is to maintain standard precautions. The best way to reduce the risk of infection in vulnerable clients is through proper handwashing and adherence to standard precautions. Option B, initiating contact isolation measures, is excessive unless the client has a confirmed infection requiring isolation. Option C, inserting an indwelling urinary catheter, actually increases the risk of infection due to the introduction of a foreign body. Option D, instructing the client in the use of adult diapers, does not directly address the risk of infection and is not as effective as maintaining standard precautions in preventing infection transmission.

2. Which parameter would be assessed to determine the degree of anxiety being experienced by the client?

• A. Memory state
• B. Creativity level
• C. Perceptual field
• D. Delusional system

Correct answer: C

Rationale: The correct parameter to assess the degree of anxiety experienced by a client is the perceptual field. As anxiety increases, perceptual fields tend to narrow. Memory state, creativity level, and delusional system are not directly related to the level of anxiety and are not appropriate parameters for determining the degree of anxiety. Memory state refers to the ability to remember, creativity level to the ability to generate new ideas or solutions, and delusional system to a set of false beliefs.

3. Which therapeutic approach would indicate the client is receiving desensitization therapy?

• A. Imagery
• B. Modeling
• C. Role playing
• D. Assertiveness training

Correct answer: A

Rationale: The correct answer is 'Imagery.' Imagery is a therapeutic approach used in desensitization therapy. It helps in facilitating positive self-talk and involves the client initiating and controlling mental pictures to correct faulty cognitions. Modeling, role-playing, and assertiveness training are effective general behavioral approaches but are not specific to desensitization therapy.

4. Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. What should the nurse do next?

• A. Clamp the catheter and recheck it in 60 minutes.
• B. Pull the catheter back 3 inches and redirect upward.
• C. Leave the catheter in place and reattempt with another catheter.
• D. Notify the healthcare provider of a possible obstruction.

Correct answer: C

Rationale: When no urine is seen in the tubing after inserting a catheter in a female client who has not voided for 8 hours, it is possible that the catheter is in the vagina rather than the bladder. Leaving the initial catheter in place can help locate the meatus for the second attempt. The client should have at least 240 mL of urine output after 8 hours, indicating the need for catheterization. Clamping the catheter (Option A) does not address the issue of incorrect catheter placement. Pulling the catheter back and redirecting it (Option B) is not effective unless the catheter is completely removed, requiring a new catheter. There is no indication of a urinary tract obstruction to notify the healthcare provider (Option D) as the catheter could be inserted easily.

5. A client who has been on hemodialysis for 2 years communicates in an angry, critical manner and does not adhere to the prescribed medications and diet. Which explanation for the client's behavior would be useful to consider in planning care?

• A. An attempt to punish the nursing staff
• B. A constructive method of accepting reality
• C. A defense against underlying depression and fear
• D. An effort to maintain life and to live it as fully as possible

Correct answer: C

Rationale: The client's angry, critical communication and non-adherence to treatment suggest underlying emotional struggles. The behavior is likely a defense mechanism against feelings of depression and fear. It is essential to consider that the client's actions are not intentionally aimed at punishing others but rather a manifestation of internal distress. Option A is incorrect as the behavior is not about punishing the nursing staff. Option B is incorrect because the behavior is not a constructive way of accepting reality but rather a maladaptive coping mechanism. Option D is incorrect as the behavior is not primarily driven by an effort to maintain life but rather by emotional distress.

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