Nursing Elites

1. During the first meeting of a therapy group, members exhibit frequent periods of silence, tense laughter, and nervous movements. Which conclusion would the nurse make?

• A. The group requires an active leader who will intervene to relieve signs of obvious stress.
• B. The group process is unhealthy and there is unwillingness to openly relate.
• C. The members are displaying expected behaviors because relationships are not yet established.
• D. The behaviors should be immediately addressed so members will not become too uncomfortable.

Correct answer: C

Rationale: During the initial stages of a therapy group, it is common for members to exhibit behaviors such as silence, tense laughter, and nervous movements. These behaviors indicate anxiety and insecurity due to the lack of established relationships and trust among the group members. This is a normal part of group development, and it does not necessarily mean that the group process is unhealthy. Intervening or addressing these behaviors immediately is not required as they are expected in the early stages of group interaction. As the group progresses and relationships are built, these behaviors are likely to diminish naturally without the need for active leader intervention. Therefore, the correct conclusion is that the members are displaying expected behaviors because relationships are not yet established. Choices A, B, and D are incorrect because active leader intervention is not necessary, the group process is not unhealthy, and addressing the behaviors immediately is not required as they are part of the early group dynamics and are expected to subside as relationships develop.

2. 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.

3. A teenager begins to cry while talking with the nurse about the problem of not being able to make friends. Which is the correct therapeutic nursing intervention?

• A. Sitting quietly with the client
• B. Telling the client that crying is not helpful
• C. Suggesting that the client play a board game
• D. Recommending how the client can change this situation

Correct answer: A

Rationale: The correct therapeutic nursing intervention in this situation is sitting quietly with the client. This approach conveys empathy, acceptance, and a willingness to listen, which can help the teenager feel supported and understood. It is important for the nurse to create a safe space for the client to express their emotions without judgment. Telling the client that crying is not helpful dismisses their feelings and can hinder the therapeutic relationship. Suggesting a board game as a distraction may prevent the client from fully exploring and addressing their emotions about the issue. Recommending how the client can change the situation may be premature at this stage, as the priority is to provide emotional support and establish trust before delving into problem-solving.

4. After attending group therapy, the client says, 'It helps to know that I'm not the only one with this type of problem.' Which concept does this statement reflect?

• A. Altruism
• B. Catharsis
• C. Universality
• D. Transference

Correct answer: C

Rationale: The client's statement reflects the concept of universality. Universality in group therapy signifies the understanding that one is not alone in their struggles, providing a sense of commonality and support among group members facing similar challenges. Altruism in group therapy involves offering support, insight, and encouragement to others, fostering personal growth and self-awareness. Catharsis pertains to group members sharing and expressing both negative and positive emotions with each other. Transference occurs when a client inadvertently projects feelings and perceptions onto the therapist that originally belonged to someone significant in their past, impacting the therapeutic relationship.

5. When bathing an uncircumcised boy older than 3 years, which action should the nurse take?

• A. Remind the child to clean his genital area.
• B. Defer perineal care because of the child's age.
• C. Retract the foreskin gently to cleanse the penis
• D. Ask the parents why the child is not circumcised

Correct answer: C

Rationale: When bathing an uncircumcised boy older than 3 years, it is essential to gently retract the foreskin to cleanse the penis. This helps in preventing the buildup of bacteria and maintaining good hygiene. Reminding the child to clean his genital area (Option A) may not be effective due to the child's cognitive development level. Perineal care should not be deferred (Option B) as it is necessary for maintaining hygiene at any age. Asking the parents why the child is not circumcised (Option D) is not relevant to the immediate care required during bathing.

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