Nursing Elites

1. The client is in the maintenance stage based on the transtheoretical model of health behavior change. Which stage is the client in?

• A. Action
• B. Preparation
• C. Maintenance
• D. Contemplation

Correct answer: C

Rationale: The client is in the maintenance stage of human behavior change. During this stage, the client has successfully incorporated the changes into their lifestyle. The maintenance stage typically begins 6 months after the action stage and continues indefinitely. The action stage lasts for 6 months from when the client initially incorporates the changes. In the preparation stage, the client starts realizing that the benefits of change outweigh the disadvantages and starts making small changes to prepare for major changes in the following month. The contemplation stage involves the client considering whether to make changes in the next 6 months. Therefore, in this scenario, the client's consistent adherence to the diet and exercise program for 8 months places them in the maintenance stage of behavior change.

2. For a client with obsessive-compulsive disorder, which reaction is most likely to occur when the performance of a ritual is interrupted?

• A. Anxiety
• B. Hostility
• C. Aggression
• D. Withdrawal

Correct answer: A

Rationale: When a client with obsessive-compulsive disorder is interrupted while performing a ritual, the most likely reaction is anxiety. The compulsive ritual serves as a coping mechanism to control anxiety, so any disruption to this ritual can heighten the individual's anxiety levels. Hostility is typically part of the disorder itself and not a direct reaction to the interruption of the ritual. Aggression may occur only if anxiety escalates to a panic level, leading to overt anger expression. Withdrawal is not a common behavioral pattern associated with obsessive-compulsive disorder and is not a typical reaction to ritual interruption.

3. By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection?

• A. Mode of transmission
• B. Portal of entry
• C. Reservoir
• D. Portal of exit

Correct answer: A

Rationale: When the nurse rolls contaminated gloves inside-out, they are manipulating the mode of transmission in the chain of infection. The gloves, which are contaminated, act as a vehicle for transferring pathogens from the reservoir's portal of exit to a potential portal of entry. Choices B, C, and D are incorrect because the action of rolling contaminated gloves does not directly relate to the portal of entry, reservoir, or portal of exit in the chain of infection.

4. The nurse plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many milliliters should the nurse administer? (Round to the nearest tenth.)

• A. 0.2 mL
• B. 0.8 mL
• C. 1.25 mL
• D. 2.0 mL

Correct answer: B

Rationale: To calculate the volume to administer, use the formula: (Volume to administer = (Ordered Dose � Volume on hand) / Dose on hand). In this case, it would be (4 mg � 1 mL) / 5 mg = 0.8 mL. Therefore, the nurse should administer 0.8 mL of diazepam. Choice A (0.2 mL) is incorrect because it miscalculates the dosage. Choice C (1.25 mL) and Choice D (2.0 mL) are incorrect as they do not align with the correct calculation based on the ordered dose and available concentration. The correct answer, 0.8 mL, is derived from accurate dosage calculation and aligns with the formula for IV medication administration, ensuring the safe and effective delivery of the medication to the client.

5. When developing Jerry's plan of care, which of the following would NOT be helpful to include?

• A. Limiting choices
• B. Providing structure
• C. Encouraging patient input
• D. Ensuring availability of PRN medications

Correct answer: A

Rationale: Limiting choices would not be helpful in Jerry's plan of care. Providing options, even if among limited choices, offers the patient a sense of independence rather than imposing control. Providing structure is crucial, especially in transitioning from a psychiatric to a medical-surgical unit. Encouraging patient input in identifying triggers and effective methods for managing aggressive impulses is essential for empowerment and individualized care. Ensuring the availability and prompt delivery of PRN medications gives the patient a sense of control and security, assuring access to necessary medication when needed.

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