Nursing Elites

1. Social support systems include all of the following except:

• A. call-in help lines
• B. emotional assistance provided by others
• C. community support groups
• D. use of coping skills and verbalization for anger management

Correct answer: D

Rationale: Social support systems involve external sources of support like call-in help lines, emotional assistance from others, and community support groups. These external resources provide individuals with assistance and comfort. Coping skills and verbalization for anger management are personal strategies that individuals use to manage emotions internally. While these skills can be beneficial, they are not considered part of external social support systems.

2. The client is admitted to the unit after a cholecystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because:

• A. The client is at risk for evisceration.
• B. The client will require frequent dressing changes.
• C. The straps provide support for drains that are inserted in the incision.
• D. No sutures or clips are used to secure the incision.

Correct answer: B

Rationale: Montgomery straps are used to secure dressings that require frequent changes due to the large amount of drainage usually present after a cholecystectomy. They are also beneficial for clients allergic to various types of tape. Answer A is incorrect as the client is not at higher risk of evisceration. Answer C is incorrect because Montgomery straps are not used to support drains. Answer D is incorrect as sutures or clips are typically used to secure the incision after gallbladder surgery, not Montgomery straps.

3. The nurse is caring for a client who is dying. While assessing the client for signs of impending death, the nurse observes the client for:

• A. elevated blood pressure.
• B. Cheyne-Stokes respiration.
• C. elevated pulse rate.
• D. decreased temperature.

Correct answer: B

Rationale: Cheyne-Stokes respirations are a pattern of breathing characterized by rhythmic waxing and waning of respirations from very deep to very shallow breathing with periods of temporary apnea. This pattern is often associated with conditions like cardiac failure and can be a sign of impending death. Elevated blood pressure and pulse rate are not typically associated with the dying process. Decreased temperature is also not a common sign of impending death. Therefore, option B, Cheyne-Stokes respiration, is the correct choice when assessing a client for signs of impending death.

4. Which information obtained from the mother of a child with cerebral palsy most likely correlates to the diagnosis?

• A. She was born at 42 weeks gestation.
• B. She had meningitis when she was 6 months old.
• C. She had physiologic jaundice after delivery.
• D. She has frequent sore throats.

Correct answer: B

Rationale: The diagnosis of meningitis at age 6 months correlates to a diagnosis of cerebral palsy. Cerebral palsy, a neurological disorder, is often associated with birth trauma or infections of the brain or spinal column. Answers A, C, and D are not related to the question. Gestational length (choice A) is not a direct risk factor for cerebral palsy. Physiologic jaundice (choice C) and frequent sore throats (choice D) are not typically associated with cerebral palsy.

5. As a type of quality indicator, an example of a structure standard is:

• A. a written philosophy.
• B. a procedure for a straight catheterization.
• C. a protocol for treatment of a client with chest pain.
• D. the diagnostic work-up for a client with abdominal pain.

Correct answer: A

Rationale: The correct answer is 'a written philosophy.' Structure standards define the conditions needed to operate a system and do not directly involve client care. Examples include philosophy, objectives, goals, hours of operation, and management responsibility. Choices B, C, and D involve specific procedures and protocols related to client care, which are not structure standards.

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