Nursing Elites

1. Gio told his nurse that the FBI is monitoring and recording his every movement and that microphones have been placed in the unit walls. Which action would be the most therapeutic response?

• A. Confront the delusional material directly by telling Gio that this simply is not so.
• B. Tell Gio that this must seem frightening to him but that you believe he is safe here.
• C. Tell Gio to wait and talk about these beliefs in his one-on-one counseling sessions.
• D. Isolate Gio when he begins to talk about these beliefs.

Correct answer: B

Rationale: The most therapeutic response in this situation is to acknowledge Gio's feelings of fear and validate his experience by expressing empathy ('this must seem frightening to him'). By reassuring Gio that he is safe in the current environment, the nurse can help reduce his anxiety and build trust. Choice A is not recommended as directly confronting delusional beliefs may lead to increased distress and resistance. Choice C delays addressing Gio's concerns and may not provide immediate support. Choice D of isolating Gio can worsen his feelings of paranoia and distrust in the treatment setting.

2. At the beginning of the shift, a nurse receives report for her daily assignment. Which of the following situations should the nurse give first priority?

• A. A diabetic client with a blood glucose level of 195 mg/dL
• B. A family member of an elderly client who has questions
• C. A client with COPD with an oxygen saturation of 84%
• D. A client who requires assistance to use the bathroom

Correct answer: C

Rationale: When prioritizing the needs of clients, the nurse must begin with the unstable client or manage conditions that affect airway, breathing, or circulation first. The client with COPD has a condition that affects breathing and is exhibiting decreased oxygen saturation levels; therefore, this client should be the first priority. Option A, the diabetic client with a blood glucose level of 195 mg/dL, does not present an immediate threat to airway, breathing, or circulation. Option B, addressing questions from a family member, is important but can be addressed after addressing critical patient needs. Option D, assisting a client to use the bathroom, is a routine task that can be prioritized after addressing urgent medical needs.

3. Plantar flexion can be prevented with ________________.

• A. foot soaks
• B. foot boards
• C. toenail care
• D. proper shoes

Correct answer: B

Rationale: Plantar flexion, or foot drop, can be prevented with foot boards, special splints, and range of motion exercises. Foot boards help maintain the foot in a neutral position, preventing contractures and deformities. Foot soaks (choice A) may help with foot hygiene but do not directly prevent plantar flexion. Toenail care (choice C) is important for overall foot health but does not prevent plantar flexion. Proper shoes (choice D) are essential for foot support and comfort but do not specifically prevent plantar flexion.

4. Which technological advance is MOST likely to place you at risk for HIPAA violations?

• A. Social media
• B. Word processing programs
• C. Spreadsheets
• D. Cloud storage services (Clouds and SOEs)

Correct answer: A

Rationale: The correct answer is Social media. Social media platforms such as Facebook can significantly put you at risk for HIPAA violations. It is crucial to never share any patient-related information or comments on social media websites, as this breaches patient confidentiality and violates HIPAA regulations. Choices B, C, and D are less likely to directly lead to HIPAA violations. Word processing programs and spreadsheets are commonly used for documentation and data organization, focusing more on internal operations and not on external sharing of sensitive information that can compromise patient confidentiality. Cloud storage services (Clouds and SOEs) are designed for secure data storage and sharing within regulated environments, and HIPAA compliance can be maintained if used appropriately. However, social media's open and unsecured nature makes it a higher risk for HIPAA violations compared to the other technological advances mentioned.

5. Which of the following is the most appropriate example of anticipatory guidance for a 16-year-old who has been hospitalized for an ankle fracture?

• A. Changes associated with puberty
• B. Driving and staying safe
• C. The health hazards of smoking
• D. Social media influences

Correct answer: B

Rationale: Anticipatory guidance is an educational process that provides information important to a client's situation. When considering a 16-year-old who has been hospitalized for an ankle fracture, the most suitable anticipatory guidance would be regarding driving and staying safe. This guidance is crucial as it is age-appropriate and relevant to preventing future injuries. Choices A, C, and D are less pertinent in this scenario. Changes associated with puberty, health hazards of smoking, and social media influences may not directly address the immediate safety concerns of a 16-year-old with an ankle fracture.

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