Nursing Elites

1. What does the E in the acronym DELIRIUM represent in causes contributing to delirium?

• A. EEG
• B. EKG
• C. Electrolytes
• D. Echocardiogram

Correct answer: C

Rationale: The E in the acronym DELIRIUM stands for Electrolytes. Electrolyte imbalances can lead to delirium. The other letters in the acronym represent: D = Dementia; L = Lung, liver, heart, kidney, brain; I = Infection; R = Rx Drugs; I = Injury, Pain, Stress; U = Unfamiliar environment; M = Metabolic. It is crucial to differentiate delirium from dementia, as delirium is often reversible with treatment of underlying causes. Dementia should only be considered after ruling out delirium, as addressing the contributing factors may alleviate the delirium state.

2. A client who just had a bilateral mastectomy is preparing to talk about body changes. Which of the following actions of the nurse is most appropriate during this discussion?

• A. Provide a room that offers minimal distractions
• B. Ask closed-ended questions to allow the client to think about her situation
• C. Write detailed notes during the conversation to track important information
• D. Ask personal questions about the client's background to determine how the procedure has affected her self-concept

Correct answer: A

Rationale: When preparing to discuss sensitive topics such as body changes post-bilateral mastectomy, it is crucial to create a conducive environment. Providing a room with minimal distractions allows the client to feel comfortable, safe, and more likely to open up about personal feelings without interruptions. This setting fosters open communication between the nurse and client, facilitating a more empathetic and supportive interaction. Closed-ended questions (Choice B) may limit the client's ability to express emotions fully. Writing detailed notes (Choice C) during the conversation may distract the nurse from actively listening and being present for the client. Asking personal questions about the client's background (Choice D) may not be appropriate during such a vulnerable discussion and could potentially create discomfort for the client.

3. Which communication technique is a part of therapeutic communication?

• A. Asking for explanations
• B. Showing sympathy to the client
• C. Asking personal questions of the client
• D. Providing relevant information to the client

Correct answer: D

Rationale: The correct answer is providing relevant information to the client. In therapeutic communication, it is essential to provide clients with all pertinent information to help them understand their health status and what to expect. This empowers clients and promotes trust in the nurse-client relationship. Asking for explanations, showing sympathy, and asking personal questions are examples of nontherapeutic communication techniques. Asking personal questions can intrude on the client's privacy and may not be relevant to their care. Showing sympathy, while well-intentioned, may come across as pity rather than true empathy. Asking for explanations can sometimes put clients on the defensive rather than fostering a collaborative dialogue.

4. 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.

5. A client who has been told she needs a hysterectomy for cervical cancer reports being upset about being unable to have a third child. Which action would the nurse take?

• A. Evaluate her willingness to pursue adoption.
• B. Encourage her to focus on her own recovery.
• C. Emphasize that she does have two children already.
• D. Ensure that other treatment options for her are explored.

Correct answer: D

Rationale: In this scenario, the nurse should ensure that other treatment options for the client are explored. While a hysterectomy may be necessary for cervical cancer, conservative management options like cervical conization and laser treatment may allow for future pregnancies. It is crucial for the nurse to inform the client of all available treatment choices. Evaluating the client's willingness to pursue adoption is not directly addressing the client's concerns about fertility. Encouraging the client to focus on her own recovery and emphasizing that she already has two children dismiss the client's distress over not being able to have a third child, which is important to acknowledge in a sensitive manner.

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