Nursing Elites

1. The nurse finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse implement first?

• A. Instruct an unlicensed assistive personnel (UAP) to stay and keep talking to the client.
• B. Sit quietly in the client's room until the client leaves the bathroom.
• C. Allow the client to cry alone and leave the client in the bathroom.
• D. Talk to the client and attempt to find out why the client is crying.

Correct answer: D

Rationale: When encountering a client in distress, the nurse's initial response should be to communicate with the client to assess the situation and provide support. By talking to the client and attempting to find out the reason for their distress, the nurse can offer appropriate assistance and ensure the client's well-being. This action prioritizes the client's emotional needs and helps establish a therapeutic relationship, which is essential in nursing care.

2. After surgery, a client who had a colostomy says 'I know the doctor did not really do a colostomy'. The nurse understands that the client is in an early stage of adjustment to the diagnosis or surgery. What nursing action is indicated at this time?

• A. Agree with the client until they are ready to accept the colostomy.
• B. Say 'It must be difficult to have this kind of surgery'.
• C. Force the client to look at their colostomy.
• D. Ask the surgeon to explain the surgery to the client.

Correct answer: B

Rationale: Acknowledging the client's feelings with empathy is essential in the early stage of adjustment to a colostomy surgery. By saying 'It must be difficult to have this kind of surgery,' the nurse validates the client's emotions and opens up a channel for further communication. Choice A is incorrect because agreeing with the client's denial is not therapeutic and may hinder acceptance. Choice C is inappropriate as it disregards the client's emotional state and autonomy. Choice D involves the surgeon and is not the nurse's role in addressing the client's emotional needs.

3. A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She states, 'I have been told that it is harmful to bathe during my period.' Which action should the nurse take first?

• A. Accept and document the client's wish to refrain from bathing.
• B. Offer to give the client a bed bath, avoiding the perineal area.
• C. Obtain written brochures about menstruation to give to the client.
• D. Teach the importance of personal hygiene during menstruation to the client.

Correct answer: D

Rationale: The priority for the nurse is to educate the client on the importance of personal hygiene during menstruation. Although it's crucial to respect the client's beliefs, providing education ensures the client receives accurate information to make informed decisions about her hygiene practices. By offering teaching first, the nurse can address any misconceptions or concerns the client may have while promoting optimal hygiene practices for overall well-being. Choice A should not be the first action as it does not address the client's potential misinformation about hygiene. Choice B is not ideal as it only offers a temporary solution without addressing the underlying issue. Choice C is not the priority as the immediate concern is the client's personal hygiene practices.

4. When a client has suffered severe burns all over his body, the most effective method of monitoring the cardiovascular system is:

• A. Cuff blood pressure.
• B. Arterial pressure.
• C. Pulmonary artery pressure.
• D. Central venous pressure.

Correct answer: D

Rationale: Central venous pressure (CVP) monitoring is the most effective method to assess fluid status and the cardiovascular system in a client with severe burns. Severe burns can lead to significant fluid shifts and hemodynamic changes, making central venous pressure monitoring crucial for guiding fluid resuscitation and managing cardiovascular stability in these patients.

5. The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective?

• A. If I exercise at least two times weekly for one hour, I will lower my cholesterol.
• B. I need to avoid eating proteins, including red meat.
• C. I will limit my intake of beef to 4 ounces per week.
• D. My blood level of low density lipoproteins needs to increase.

Correct answer: C

Rationale: Limiting saturated fat from animal food sources to no more than 4 ounces per week is an important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per week. Red meat and all proteins do not need to be eliminated to lower cholesterol, but should be restricted to lean cuts of red meat and smaller portions. The low density lipoproteins need to decrease rather than increase.

Similar Questions