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 instruction should the nurse provide to a preschool-age client to prevent altered growth and development?

• A. Trust
• B. Empathy
• C. Impulse control
• D. Problem-solving

Correct answer: C

Rationale: Teaching a preschool-age child and their parents about the importance of impulse control is essential to prevent the risk of altered growth and development. Preschool-age children are at a stage where they are developing self-regulation skills, so teaching them to manage their impulses can help in their overall growth and development. Trust is a critical concept taught during infancy to foster secure attachments. Empathy is crucial for parents of toddlers to understand their child's emotions. Problem-solving skills are typically emphasized for school-age children to enhance cognitive development.

3. A neonate born at 32 weeks' gestation and weighing 3 lb (1361 g) is admitted to the neonatal intensive care unit (NICU). When would the nurse take the neonate's mother to visit the infant?

• A. When the infant's condition has stabilized
• B. When the infant is out of immediate danger
• C. When the primary health care provider has provided written permission
• D. When the mother is well enough to be taken to the NICU

Correct answer: D

Rationale: The mother should see her infant as soon as possible to acknowledge the reality of the birth and begin bonding. Delaying the visit may impede maternal-infant bonding. The timing of the mother's visit should be based on her physical and emotional readiness, not solely on the infant's condition or the need for written permission. The nurse can independently facilitate the mother's visit without requiring a prescription from the primary healthcare provider.

4. What initial response would the nurse give to a husband who is upset that his wife's alcohol withdrawal delirium has persisted for a second day?

• A. "I see that you're worried. We're using medication to ease your wife's discomfort."?
• B. "This is expected. I suggest that you go home because there's nothing you can do to help."?
• C. "If you're afraid that she will die, I assure you, very few alcoholics die during detoxification."?
• D. "If you are concerned that she is uncomfortable, I'm sure that she's not in pain."?

Correct answer: A

Rationale: The correct response is to acknowledge the husband's feelings and provide information on the treatment plan to alleviate his concerns. This approach validates his emotions and educates him on the steps being taken to help his wife, promoting understanding and reducing anxiety. Choice B is incorrect as it dismisses the husband's worries and implies helplessness, potentially increasing his distress. Choice C is inappropriate as it introduces the concept of death, which can heighten fear and anxiety in the husband. Choice D is not recommended as it provides reassurance about the wife's pain without accurate knowledge of her discomfort, which could undermine trust and communication between the nurse and the husband.

5. Which term or description would the nurse use for a client who repeatedly performs ritualistic behaviors throughout the day to limit anxious feelings?

• A. Obsessions
• B. Compulsions
• C. Under personal control
• D. Related to rebelliousness

Correct answer: B

Rationale: The correct answer is 'Compulsions.' A compulsion is an uncontrollable, persistent urge to perform an act repetitively to relieve anxiety. In this scenario, the client's repetitive ritualistic behaviors are indicative of compulsions. Obsessions, on the other hand, are persistent ideas, thoughts, or impulses that cannot be eliminated with logical reasoning. The behavior is not under personal control because avoiding it increases anxiety, making it a defense mechanism. It is not related to rebelliousness; instead, clients engage in these behaviors to reduce anxiety.

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