Nursing Elites

1. Ruth is a 72-year-old patient who has been upset and crying all morning. When asked why she is upset, she turns toward the wall in silence. What collaborative process may be helpful in caring for this patient?

• A. Speak with the patient care technician
• B. Call the chaplain
• C. Call the social worker
• D. Call the patient's husband

Correct answer: A

Rationale: Collaborating with the patient care technician is an appropriate approach in this scenario. Patient care technicians and nurses' aides often provide direct care to patients, developing a closer relationship with them. Patients may feel more comfortable sharing their feelings with these caregivers compared to other healthcare professionals. In this situation, Ruth's distress appears more emotional than spiritual, making it more suitable to speak with someone directly involved in her care. Calling the chaplain (Choice B) might not directly address Ruth's immediate emotional needs as it could focus more on spiritual support. Involving the social worker (Choice C) could help address underlying emotional or social issues, but speaking with the patient care technician is a more direct and immediate step to assess and provide initial support. Calling the patient's husband (Choice D) may not address Ruth's immediate emotional distress and may not be appropriate without understanding the root cause of her upset.

2. A client is receiving education on cholesterol. Which of the following statements from the client indicates the need for further teaching?

• A. I would like my HDL levels to be over 50.
• B. It is better for me to have high HDL levels and low LDL levels.
• C. It is better for me to have high LDL levels and low HDL levels.
• D. My goal is to get my total cholesterol below 200.

Correct answer: C

Rationale: The correct answer is, 'It is better for me to have high LDL levels and low HDL levels.' This statement indicates a need for further teaching because high LDL levels contribute to atherosclerosis, while high HDL levels can protect against heart disease. The client should understand the importance of lowering LDL levels and increasing HDL levels to maintain good heart health. Choice A is correct as desiring HDL levels over 50 is a positive goal. Choice B is correct as it reflects the ideal scenario of high HDL and low LDL levels. Choice D is correct as a total cholesterol below 200 is a common goal for heart health. Therefore, Choice C is incorrect as it suggests an opposite and unhealthy relationship between LDL and HDL levels.

3. Mr. N is a client who entered the hospital with a diagnosis of diabetic ketoacidosis. The nurse enters his room to check his vital signs and finds him breathing at a rate of 32 times per minute; his respirations are deep and regular. Which type of respiratory pattern is Mr. N most likely exhibiting?

• A. Kussmaul respirations
• B. Cheyne-Stokes respirations
• C. Biot's respirations
• D. Cluster breathing

Correct answer: A

Rationale: Mr. N is exhibiting Kussmaul respirations, characterized by rapid, deep, and regular breathing. This type of respiratory pattern is commonly seen in metabolic acidosis, such as in diabetic ketoacidosis. Kussmaul respirations are a form of hyperventilation, leading to the elimination of carbon dioxide from the body. Choice B, Cheyne-Stokes respirations, is characterized by alternating periods of deep, rapid breathing followed by periods of apnea and is not typically associated with diabetic ketoacidosis. Choice C, Biot's respirations, involve irregular breathing patterns with periods of apnea and are not reflective of the described breathing pattern. Cluster breathing, as mentioned in Choice D, is not a recognized term in respiratory patterns and does not describe the breathing pattern observed in Mr. N.

4. A complication of osteoporosis is _______________?

• A. rheumatoid arthritis
• B. gouty arthritis
• C. dorsiflexion
• D. joint deformity

Correct answer: D

Rationale: Joint deformity is a well-known complication of osteoporosis, leading to structural changes in the joints due to bone loss and fragility. Gouty arthritis and rheumatoid arthritis are distinct types of arthritis that are not direct complications of osteoporosis. Dorsiflexion is a movement related to the foot's range of motion and is not a typical complication of osteoporosis.

5. A client is seen in the emergency room as a victim of suspected domestic violence. The nurse's aide brings the client to a center curtained area, gives her a gown to change into, and asks her to wait for the nurse. What is the most appropriate action of the nurse upon arrival?

• A. Ask the client to undress to assess for injuries
• B. Take the client into a private room
• C. Notify the police to file a report
• D. Notify the house supervisor to keep security on alert

Correct answer: B

Rationale: When dealing with a client suspected of domestic violence, it is crucial to provide privacy and a safe environment. Taking the client into a private room allows for a confidential conversation and assessment without compromising the client's safety or dignity. The nurse should prioritize creating a safe space for the client to share information and receive support. Notification of authorities should only occur once a thorough assessment has been conducted to ensure the client's safety and well-being. Option A is incorrect because asking the client to undress should be done with sensitivity and respect for the client's privacy, focusing on assessing injuries rather than visualizing them. Option C is premature as involving the police should be based on a comprehensive assessment and the client's consent. Option D is not the most immediate and direct action required to address the client's immediate needs in a suspected domestic violence situation.

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