Nursing Elites

1. 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.

2. A 12-year-old male is brought to his primary care provider to determine whether sexual abuse has occurred. The mother states, 'Because there is no permanent physical damage, he does not need any more treatment.' The nurse's response should be based on which of the following pieces of information?

• A. Male victims of sexual abuse can have long-term psychological problems.
• B. Survivors of male sexual abuse might become confused about their sexual identity.
• C. Not all male sex abuse survivors grow up to abuse other children.
• D. The needs of sexually abused children can vary based on gender and individual circumstances.

Correct answer: B

Rationale: Male children are sexually abused nearly as often as female children. Perpetrators are usually men but can be women. Needs of male children who have been sexually abused might be different from the needs of female survivors. Male survivors might respond in anger, question their sexuality, use alcohol and other drugs, and might try to prove their masculinity by performing daring acts. Choice A is incorrect because male victims of sexual abuse can indeed have long-term psychological problems. Choice C is incorrect as not all male sex abuse survivors grow up to abuse other children. Choice D is incorrect as the needs of sexually abused children can vary based on gender and individual circumstances.

3. The nurse who was not promoted then went to the utility room and slammed several cupboard doors while looking for Kleenex. This behavior exemplifies:

• A. displacement.
• B. sublimation
• C. conversion.
• D. reaction formation.

Correct answer: A.

Rationale: Displacement unconsciously transfers emotions associated with a person, object, or situation to another less threatening person, object, or situation. In this scenario, the nurse slammed doors instead of expressing anger towards the promoted nurse or the administrator who made the promotion decision. Sublimation is the unconscious process of substituting constructive activity for unacceptable impulses. Since slamming cupboard doors is not a constructive activity, this choice is incorrect. Conversion involves transforming anxiety into physical symptoms, which is not demonstrated in the given behavior. Reaction formation keeps unacceptable feelings or behaviors out of awareness by displaying the opposite feeling or behavior, which is not the case here.

4. The nursing assistant hitting the client in the long-term care facility can be charged with:

• A. Negligence
• B. Tort
• C. Assault
• D. Malpractice

Correct answer: C

Rationale: Assault is the appropriate charge in this scenario. Assault involves physically striking or touching someone inappropriately. Negligence (Choice A) refers to failing to provide proper care for the client. Tort (Choice B) is a wrongful act committed against the client or their property. Malpractice (Choice D) is the failure to perform an act that should have been done or the improper performance of an act resulting in harm to the client. Since the nursing assistant physically struck the client, the charge of assault is most fitting.

5. A client is admitted with a diagnosis of Multiple Drug Use. The nurse should plan care based on knowledge that

• A. Multiple drug use is common.
• B. People might use more than one drug to enhance the effect or relieve withdrawal symptoms.
• C. Combining alcohol and barbiturates can be dangerous due to their combined depressant effects.
• D. Assessment and intervention are more complex with multiple drug use due to the synergistic effects.

Correct answer: B

Rationale: When caring for a client with Multiple Drug Use, it is important to understand that individuals may use more than one drug simultaneously or sequentially to enhance the effect of a particular drug or to relieve withdrawal symptoms. This practice is common among substance users. For example, heroin users may also consume alcohol, marijuana, or benzodiazepines. Combining drugs can have various effects, such as intensifying intoxication or alleviating withdrawal symptoms. It is crucial to recognize that multiple drug use can complicate assessment and intervention due to the diverse effects of different substances on the client's health. Option A is incorrect as multiple drug use is indeed common, not uncommon. Option C is incorrect because combining alcohol and barbiturates can be dangerous due to their combined depressant effects. Option D is incorrect because multiple drug use complicates assessment and intervention rather than making them easier, as the effects of different drugs on the client need to be carefully considered.

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