Nursing Elites

1. Nursing behaviors associated with the implementation phase of the nursing process are concerned with:

• A. participating in the mutual identification of patient outcomes.
• B. gathering accurate and sufficient patient-centered data.
• C. comparing patient responses and expected outcomes.
• D. carrying out interventions and coordinating care.

Correct answer: D

Rationale: During the implementation phase of the nursing process, nurses focus on executing interventions and coordinating care. This involves utilizing available resources, performing necessary interventions, exploring alternatives when needed, and collaborating with other healthcare team members to ensure comprehensive care delivery. Choice A is incorrect as it pertains more to the planning phase where patient outcomes are identified. Choice B is incorrect as it relates to data collection, which is primarily a part of the assessment phase. Choice C is incorrect as it involves evaluating patient responses against expected outcomes, which is part of the evaluation phase.

2. Which action by a client who requires an above-the-knee amputation for peripheral arterial disease best indicates emotional readiness for the surgery?

• A. Explains the goals of the procedure
• B. Displays few signs of anticipatory grief
• C. Participates in learning perioperative care
• D. Verbalizes acceptance of permanent dependency needs

Correct answer: C

Rationale: Participating actively in learning self-care demonstrates emotional acceptance of the need for surgery and readiness for planning post-surgery. Explaining the goals of the procedure may reflect intellectual readiness but not necessarily emotional readiness. A client who shows few signs of anticipatory grief may be suppressing emotions or in denial, which can hinder the emotional readiness. Verbalizing acceptance of permanent dependency needs suggests the client may require further education and emotional support, as it may not reflect a healthy emotional readiness for the surgery.

3. For a client with obsessive-compulsive disorder, which reaction is most likely to occur when the performance of a ritual is interrupted?

• A. Anxiety
• B. Hostility
• C. Aggression
• D. Withdrawal

Correct answer: A

Rationale: When a client with obsessive-compulsive disorder is interrupted while performing a ritual, the most likely reaction is anxiety. The compulsive ritual serves as a coping mechanism to control anxiety, so any disruption to this ritual can heighten the individual's anxiety levels. Hostility is typically part of the disorder itself and not a direct reaction to the interruption of the ritual. Aggression may occur only if anxiety escalates to a panic level, leading to overt anger expression. Withdrawal is not a common behavioral pattern associated with obsessive-compulsive disorder and is not a typical reaction to ritual interruption.

4. A client who is at 28 weeks' gestation and in active labor is crying. She says, 'I just know that this baby is going to die. What's the use of doing all this to save it?' Which explanation would interpret the client's statements?

• A. She is depressed and needs gentle, positive support during labor.
• B. She is experiencing anticipatory grief and withdrawing from bonding.
• C. She is in need of emotional support to help her cope with the impending birth.
• D. She is struggling to cope with the birth by using the word 'it.'

Correct answer: B

Rationale: The client's statement indicates anticipatory grief, where she is preparing for a potential loss. This grief is not necessarily about the literal death of the baby but about the loss of the anticipated healthy full-term baby. The client may not be ready to bond with the reality of a preterm baby. Providing gentle, positive support is essential to help her cope with her feelings, as firm support may come across as dismissive. Sedation is not appropriate as it could hinder the client's emotional processing. Allowing the client to express her emotions and work through anticipatory grieving is crucial. The use of the word 'it' reflects the client's emotional struggle and is not the primary issue at hand.

5. According to Erikson's theory, which behavior would the nurse expect a preschooler to exhibit?

• A. The child develops the superego.
• B. The child plays beside other children.
• C. The child concentrates on work and play.
• D. The child becomes casual about body appearance.

Correct answer: A

Rationale: According to Erikson's theory, a preschooler develops the superego or conscience during the initiative versus guilt stage. This stage occurs around ages 3 to 6 years old. The development of the superego is crucial for the child to start understanding and internalizing societal and parental values. Choice B is incorrect because playing beside other children typically occurs during the autonomy versus shame and doubt stage, which is seen in toddlers. Choice C is incorrect as concentrating on work and play is more characteristic of the industry versus inferiority stage, typically seen in school-aged children. Choice D is incorrect because becoming casual about body appearance is more aligned with the identity versus role confusion stage, which is seen in adolescents who have a marked preoccupation with appearance and body image.

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