Nursing Elites

1. Before assessing a new patient, a nurse is told by another healthcare worker, "I know that patient. No matter how hard we work, there isn't much improvement by the time of discharge."? The nurse's responsibility is to:

• A. document the other worker's assessment of the patient.
• B. assess the patient based on data collected from all sources.
• C. validate the worker's impression by contacting the patient's significant other.
• D. discuss the worker's impression with the patient during the assessment interview

Correct answer: B

Rationale: The correct answer is to assess the patient based on data collected from all sources. It is important for the nurse to gather information from various sources to form an objective assessment. Biased assessments by others should be evaluated as objectively as possible by the nurse, considering the potential impact of counter-transference. Documenting the other worker's assessment (Choice A) may be necessary for thorough documentation but should not influence the nurse's independent assessment. Validating the worker's impression by contacting the patient's significant other (Choice C) may not provide an accurate representation of the patient's condition. Discussing the worker's impression with the patient during the assessment interview (Choice D) can introduce bias and may not lead to an objective evaluation.

2. When developing Jerry's plan of care, which of the following would NOT be helpful to include?

• A. Limiting choices
• B. Providing structure
• C. Encouraging patient input
• D. Ensuring availability of PRN medications

Correct answer: A

Rationale: Limiting choices would not be helpful in Jerry's plan of care. Providing options, even if among limited choices, offers the patient a sense of independence rather than imposing control. Providing structure is crucial, especially in transitioning from a psychiatric to a medical-surgical unit. Encouraging patient input in identifying triggers and effective methods for managing aggressive impulses is essential for empowerment and individualized care. Ensuring the availability and prompt delivery of PRN medications gives the patient a sense of control and security, assuring access to necessary medication when needed.

3. During a scheduled health maintenance visit, which common source of stress for a 6-year-old client would the nurse include in the teaching session?

• A. Wanting to be first
• B. Demanding privacy
• C. Having a desire to be like an idol
• D. Being more selective with playmates

Correct answer: A

Rationale: A common source of stress for a 6-year-old school-age client is competition, such as wanting to be first or the best (winning). This aspect can create stress for a 6-year-old as they navigate social interactions and activities. Therefore, the nurse would address this issue during the teaching session at the health maintenance visit. Demanding privacy, having a desire to be like an idol, and being more selective with playmates are characteristics more commonly associated with 7-year-old clients, not typically seen in the stressors of a 6-year-old. Understanding age-appropriate stressors is crucial for providing tailored education and support in pediatric care.

4. What is the nurse's initial plan for providing pain relief measures during labor for a pregnant client with a history of opioid abuse?

• A. Scheduling pain medication at regular intervals
• B. Administering the medication only when the pain is severe
• C. Avoiding the administration of medication unless it is requested
• D. Recognizing that less pain medication will be needed by this client compared with other women in labor

Correct answer: A

Rationale: In a pregnant client with a history of opioid abuse, scheduling pain medication at regular intervals is the initial plan for providing pain relief during labor. This client may have a lower tolerance for pain and a greater need for pain relief. If medication is only administered when the pain is severe, larger doses may be needed, leading to increased anxiety and discomfort. Avoiding medication unless requested is not ideal, as proactive pain management is crucial during labor. Recognizing that less pain medication will be needed by this client compared with others is incorrect, as individuals with a history of opioid abuse often require more medication due to tolerance to addictive drugs.

5. While obtaining a lie-sit-stand blood pressure reading on a client, what action is most important for the nurse to implement?

• A. Stay with the client while the client is standing.
• B. Record the findings on the graphic sheet in the chart.
• C. Keep the blood pressure cuff on the same arm.
• D. Record changes in the client's pulse rate.

Correct answer: A

Rationale: The most crucial action for the nurse to implement when obtaining a lie-sit-stand blood pressure reading is to stay with the client while the client is standing. This is essential to monitor the client's immediate response to position changes and ensure their safety. Recording the findings on the graphic sheet is important for documentation but is not as critical as staying with the client. Keeping the blood pressure cuff on the same arm helps maintain consistency in readings but is not as vital as ensuring client safety. Recording changes in the client's pulse rate is important for a comprehensive assessment but does not take precedence over monitoring the client during position changes.

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