Nursing Elites

1. The nurse assesses a client for physiological risk factors for falls. The nurse should conclude that the client is not at risk if which of the following is discovered?

• A. history of dizziness
• B. need for a wheelchair due to reduced mobility
• C. weakness and fatigue noted when climbing stairs
• D. intact recent and remote memory

Correct answer: D

Rationale: The correct answer is intact recent and remote memory. Intact memory function indicates that the client is less likely to be at risk for falls as it suggests cognitive awareness and orientation, which are important for safety. Choices A, B, and C are risk factors for falls: a history of dizziness can lead to imbalance, the need for a wheelchair due to reduced mobility can increase fall risk, and weakness and fatigue when climbing stairs indicate physical limitations that predispose a client to falls. Therefore, these options would suggest an increased risk for falls.

2. What is the most appropriate feeding method for a client who is unable to swallow?

• A. Nothing by mouth
• B. Nasogastric feedings
• C. Clear liquids
• D. Total parenteral nutrition

Correct answer: B

Rationale: Nasogastric feedings are the most appropriate feeding method for a client who is unable to swallow. Providing nothing by mouth can lead to nutritional deficiencies, while clear liquids might cause aspiration. Total parenteral nutrition is not necessary if the gastrointestinal tract is functional. Nasogastric feedings are preferred as they can safely provide nutrition without the risks associated with not eating or aspirating.

3. A client who had a stroke has left-side weakness and is having difficulty holding utensils while eating. To which of these services does the nurse suggest a referral?

• A. Physical therapy
• B. Occupational therapy
• C. Home care
• D. Social services

Correct answer: B

Rationale: An occupational therapist assists clients with impairments in performing activities of daily living, such as feeding themselves with the use of adaptive devices. In this case, the client needs help with holding utensils while eating, falling under the scope of occupational therapy. Home care provides general support services but doesn't specifically address the client's need for utensil use. Social services focus on counseling and financial aspects of care, not physical rehabilitation like occupational therapy does. Physical therapy primarily deals with physical disabilities through exercises, which is not the primary concern for the client's difficulty in holding utensils.

4. A director of nursing at a long-term care center has announced a change to computerized documentation of nursing care. A certified nursing assistant (CNA) on the team, resistant to the change, is not taking an active part in facilitating the implementation of the new procedure. Which strategy would be the best approach to dealing with the conflict?

• A. Meeting with the CNA and encouraging him to express his feelings regarding the change
• B. Ignoring the resistance
• C. Telling the CNA that a licensed practical nurse (LPN) will perform all computer documentation while he documents intake and output and vital signs
• D. Telling the CNA that noncompliance will be documented in the personnel record

Correct answer: A

Rationale: The best approach to dealing with resistance to change is through open communication and understanding. Meeting with the CNA and encouraging him to express his feelings regarding the change allows for a constructive dialogue where issues can be addressed, and alternative solutions can be explored. Ignoring the resistance does not help in resolving the conflict and may lead to further issues. Telling the CNA that a licensed practical nurse (LPN) will perform all computer documentation while he documents intake and output and vital signs does not address the underlying concerns of the CNA and may create more resistance. Threatening the CNA with noncompliance consequences may escalate the resistance and create a negative work environment.

5. In which situation is the nurse upholding the ethical principle of fidelity?

• A. Providing complete information regarding treatment options to a client with newly diagnosed cancer
• B. Allowing a client to decide when to receive daily hygiene care
• C. Inserting a 19-gauge intravenous catheter into a client requiring a blood transfusion
• D. Contacting the health care provider about the client's request to incorporate complementary therapies for pain into the treatment plan

Correct answer: D

Rationale: Fidelity is the ethical principle of keeping promises made to clients, families, and other healthcare professionals. Contacting the health care provider about the client's request to incorporate complementary therapies for pain into the treatment plan exemplifies fidelity. By advocating for the client's preferences and ensuring their requests are addressed, the nurse demonstrates a commitment to fulfilling promises made to the client. Allowing a client to decide when to receive daily hygiene care relates to respecting autonomy, not fidelity. Inserting a 19-gauge intravenous catheter into a client needing a blood transfusion aligns with beneficence, as it involves taking action to provide necessary treatment. Providing complete information to a client with newly diagnosed cancer about treatment options reflects justice, promoting fairness and equity in healthcare by offering equal access to information and treatment choices.

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