Nursing Elites

1. Which action often triggers an episode of violence or aggression in a patient with a psychiatric diagnosis involving violent behavior?

• A. Obtaining a history
• B. Asking for input into care
• C. Enforcing rules
• D. Taking a walk

Correct answer: C

Rationale: Enforcing rules is often a trigger for patients with psychiatric diagnoses involving violent behavior. Limit-setting or denying patient demands can be perceived as control and intimidation, leading to aggressive responses. Nursing staff must respond calmly and professionally to prevent escalation. Avoiding such patients or matching their emotions can worsen the situation. Therefore, enforcing rules can provoke violent episodes in these patients.

2. A child is undergoing chemotherapy to treat a neuroblastoma, stage IV, and had his first chemotherapy session last week. He arrives with his mother for this week's session. How would the nurse greet the child?

• A. How did you feel after your last treatment?
• B. What are your thoughts on the treatment so far?
• C. Did you experience any side effects after the last session?
• D. Are you ready for the next round of treatment?

Correct answer: A

Rationale: The most appropriate way for the nurse to greet the child is by asking, 'How did you feel after your last treatment?' This question allows the child to share their experience voluntarily, empowering them to feel in control of the conversation. It also demonstrates empathy and a caring attitude. Option B, 'What are your thoughts on the treatment so far?' is broad and may not address the child's immediate feelings after the last session. Option C, 'Did you experience any side effects after the last session?' focuses solely on side effects and may predispose the child to think negatively. Option D, 'Are you ready for the next round of treatment?' does not address the child's current well-being or feelings, missing an opportunity for emotional support and connection.

3. The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which observation of this procedure requires the nurse's intervention?

• A. The cuff wraps around the girth of the leg.
• B. The UAP auscultates the popliteal pulse with the cuff on the lower leg.
• C. The client is placed in a prone position.
• D. The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.

Correct answer: B

Rationale: When obtaining blood pressure in the lower extremities, the popliteal pulse should be auscultated when the blood pressure cuff is applied around the thigh. The nurse should intervene when the UAP is auscultating the popliteal pulse with the cuff on the lower leg because this is incorrect placement. Option A, wrapping the cuff around the girth of the leg, ensures an accurate assessment. Option C, placing the client in a prone position, provides the best access to the artery. The systolic pressure in the popliteal artery is typically 10 to 40 mm Hg higher than in the brachial artery, so a systolic reading 20 mm Hg higher than the blood pressure in the client's arm is within the expected range and does not require intervention.

4. According to the CDC, which of the following age groups is most likely to meet the criteria for major depression?

• A. 18-24 years
• B. 25-34 years
• C. 35-44 years
• D. 45-64 years

Correct answer: D

Rationale: According to the CDC, individuals aged 45-64 years are most likely to meet the criteria for major depression. While patients in the 18-24 year age group are more likely to report symptoms of depression, when it comes to major depression, the prevalence is higher in the 45-64 year age group. Choices A, B, and C are incorrect because the CDC indicates that major depression is most prevalent in the 45-64 year age group.

5. A 5-year-old child has been recently admitted to the hospital. According to Erik Erikson's psychosocial development stages, the child is in which stage?

• A. Trust vs. mistrust
• B. Initiative vs. guilt
• C. Autonomy vs. shame and doubt
• D. Intimacy vs. isolation

Correct answer: B

Rationale: The correct answer is 'Initiative vs. guilt.' According to Erik Erikson's psychosocial development stages, children aged 3-6 years old are in the stage of initiative versus guilt. During this stage, children begin to assert their power and control over the environment. They develop a sense of purpose and direction, but may also experience feelings of guilt if they believe their actions have caused harm or conflict. Choices A, C, and D are incorrect. 'Trust vs. mistrust' is the first stage for infants, 'Autonomy vs. shame and doubt' is the second stage for toddlers, and 'Intimacy vs. isolation' is a stage that occurs later in adulthood.

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