Nursing Elites

1. The nurse is assessing a young client who presents with recurrent gastrointestinal disorders. On further assessment, the nurse learns that the client is experiencing job-related pressures. Which is the most important nursing intervention for this client?

• A. Educate the client on managing stress.
• B. Teach the client to maintain a balanced diet.
• C. Instruct the client to have regular health checkups.
• D. Ask the client to use sunscreen when working outdoors.

Correct answer: A

Rationale: The most important nursing intervention for a client experiencing job-related pressures and recurrent gastrointestinal disorders is to educate the client on managing stress. Stress is a lifestyle risk factor that can impact both mental health and physical well-being. It is associated with various illnesses, including gastrointestinal disorders. Teaching the client to maintain a balanced diet is important for preventive care and health promotion but is not the priority in this scenario. While instructing the client to have regular health checkups is essential for overall health maintenance, addressing the root cause of stress is crucial in this case. Asking the client to use sunscreen when working outdoors is important for sun protection and skin cancer prevention but not directly related to the client's job-related stress and gastrointestinal issues.

2. The client is still unable to sleep despite following the progressive muscle relaxation technique routine taught by the nurse. Which action should the nurse take first?

• A. Instruct the client to add regular exercise to their daily routine.
• B. Determine if the client has been keeping a sleep diary.
• C. Encourage the client to continue the routine until sleep is achieved.
• D. Ask the client to describe the routine they are currently following.

Correct answer: D

Rationale: The nurse's initial step should be to assess the client's adherence to the original instructions. By asking the client to describe the routine they are following, the nurse gains more specific information than relying solely on a sleep diary. This information will help the nurse identify any deviations or areas needing adjustment in the technique. Encouraging the client to persist with an unsuccessful routine without evaluation is not beneficial. Adding regular exercise, although important for overall sleep health, should come after ensuring the correct execution of the relaxation technique.

3. The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction?

• A. Perform range-of-motion exercises to prevent contractures.
• B. Decrease the client's fluid intake to prevent diarrhea.
• C. Massage the client's legs to reduce embolism occurrence.
• D. Turn the client from side to back every shift.

Correct answer: A

Rationale: Performing range-of-motion exercises is beneficial in reducing contractures around joints, maintaining joint mobility, and preventing stiffness in immobile clients. This intervention helps preserve muscle strength and joint function. Options B, C, and D are incorrect because: Option B suggesting decreasing fluid intake to prevent diarrhea is not relevant to preventing complications of immobility and could lead to dehydration; Option C, massaging the client's legs to reduce embolism occurrence, is not a recommended practice as massage can dislodge blood clots and increase the risk of embolism; Option D, turning the client from side to back every shift, is not sufficient as it does not address the need for maintaining joint mobility and preventing contractures in immobile clients.

4. To reduce the risk of venous thrombosis, which measure should the nurse instruct the client in to promote venous return?

• A. Instruct in the use of the incentive spirometer.
• B. Elevate the head of the bed during all meals.
• C. Use aseptic technique to change the dressing.
• D. Encourage frequent ambulation in the hallway.

Correct answer: D

Rationale: To prevent venous thrombus formation, promoting venous return is crucial. Encouraging frequent ambulation in the hallway helps prevent venous stasis and reduces the risk of thrombus formation in immobile clients. Option A (using the incentive spirometer) aids in alveolar expansion to prevent atelectasis, not specifically venous thrombosis. Option B (elevating the head of the bed during meals) reduces the risk of aspiration, not venous thrombosis. Option C (using aseptic technique for dressing changes) reduces the risk of postoperative infection, not specifically venous thrombosis. Therefore, among the options provided, encouraging frequent ambulation in the hallway is the most effective measure to prevent venous thrombosis.

5. When a man with dementia is admitted to a long-term care facility, his wife, who appears tired and angry, says in a sarcastic tone, 'Let's see what you can do with him.' Which response is therapeutic?

• A. It sounds like it's been difficult for you.'
• B. I don't understand what you mean.'
• C. 'I have experience with all types of clients.'
• D. It's too bad you didn't admit him sooner.'

Correct answer: A

Rationale: The correct response is to acknowledge the caregiver's feelings and challenges without blaming them. Option A, 'It sounds like it's been difficult for you,' shows empathy and opens the channel of communication. Options B and C, 'I don't understand what you mean' and 'I have experience with all types of clients,' are nurse-focused responses that block effective communication. Option D, 'It's too bad you didn't admit him sooner,' is a hostile response that shifts the blame to the caregiver, which is not therapeutic in this situation.

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