Nursing Elites

1. The nurse is caring for a client with cerebral palsy. The nurse should provide frequent rest periods because:

• A. Grimacing and writhing movements decrease with relaxation and rest.
• B. Hypoactive deep tendon reflexes become more active with rest.
• C. Stretch reflexes are increased with rest.
• D. Fine motor movements are improved.

Correct answer: A

Rationale: Frequent rest periods help to relax tense muscles and preserve energy in clients with cerebral palsy. This can lead to a decrease in grimacing and writhing movements, as relaxation and rest help to alleviate muscle tension. Choices B, C, and D are incorrect because they provide inaccurate information. Hypoactive deep tendon reflexes do not become more active with rest; stretch reflexes are not increased with rest in cerebral palsy patients, and fine motor movements are not necessarily improved solely by rest.

2. A 57-year-old woman is recently widowed. She states, "I will never be able to learn how to manage the finances. My husband did all of that."? Select the nurse's response that could help raise the client's self-esteem.

• A. "You feel inadequate because you have never learned to balance a checkbook."?
• B. "You should have insisted your husband teach you about the finances."?
• C. "You are strong and will learn how to manage your finances after a while."?
• D. "I believe in your strength to learn how to manage your finances in time."?

Correct answer: C

Rationale: The nurse should aim to boost the client's self-esteem by providing positive reinforcement. By stating, "You are strong and will learn how to manage your finances after a while,"? the nurse acknowledges the client's strength and capability, encouraging her to believe in herself. Choice A is incorrect as it focuses on the client's inadequacy rather than empowering her. Choice B places unnecessary blame on the client for not taking action in the past. Choice D, though positive, slightly alters the nurse's original phrase, making choice C the most appropriate response to uplift the client's self-esteem.

3. When caring for African-American clients, what is an important consideration regarding their needs?

• A. Families may have specific needs.
• B. Special hair, skin, and nail care might be required.
• C. Cultural diets should be respected.
• D. Clients are generally future-oriented.

Correct answer: B

Rationale: Correct answer: Special hair, skin, and nail care might be required. African-American clients may have specific hair, skin, and nail care needs due to their unique characteristics such as curly hair and melanin-rich skin. It is important for healthcare providers to be knowledgeable about these needs to provide appropriate care. Option A is incorrect as it does not address the specific care aspect related to the clients themselves. Option C is incorrect as assuming all African-American clients follow cultural diets is a stereotype and may not apply to every individual. Option D is incorrect as being future-oriented is not a characteristic that is universally applicable to African-American clients and does not directly impact nursing care considerations.

4. A 10-month-old child is brought to the Emergency Department because he is difficult to awaken. The nurse notes bruises on both upper arms. These findings are most consistent with:

• A. wearing clothing that is too small for the child.
• B. the child being shaken.
• C. falling while learning to walk.
• D. parents trying to awaken the child.

Correct answer: B

Rationale: The correct answer is 'the child being shaken.' In cases of suspected child abuse, bruises on both upper arms can be indicative of a child being shaken, as children who are shaken are frequently grasped by both upper arms. The presentation of a 10-month-old child being difficult to awaken, along with bruises on the upper arms, raises concern for inflicted injury. Symptoms of brain injury associated with shaking include a decreased level of consciousness. Choices A, C, and D are less likely in this scenario as they do not align with the concerning signs of suspected abuse indicated by the bruises and the child's altered level of consciousness.

5. What is the first exercise that should be performed by a client who had a mastectomy?

• A. Walking the hand up the wall
• B. Sweeping the floor
• C. Combing her hair
• D. Squeezing a ball

Correct answer: D

Rationale: The correct answer is D: Squeezing a ball. The first exercise that should be done by a client with a mastectomy is squeezing a ball. This helps in regaining strength and mobility in the affected area. Choices A, B, and C are incorrect as they are not typically the initial exercises recommended post-mastectomy. Walking the hand up the wall, sweeping the floor, and combing hair are activities that may be introduced later in the rehabilitation process.

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