Nursing Elites

1. When caring for an elderly client and providing education, which of the following would be the least appropriate for the nurse to do?

• A. The nurse speaks loudly.
• B. The nurse allows additional time after each instruction to allow the client to process.
• C. The nurse provides supplemental written resources.
• D. The nurse breaks up the education into multiple shorter sessions.

Correct answer: A

Rationale: Speaking loudly is inappropriate when caring for an elderly client. It is essential to assess the client for a hearing impairment and provide appropriate assistance if needed. Elderly clients may require more time to process information due to slower reaction times, benefit from shorter sessions as they fatigue easily, and can absorb supplemental written resources effectively. Therefore, speaking loudly may not be conducive to effective communication and may not cater to the specific needs of the elderly client, unlike the other options provided.

2. During a well-baby examination, the nurse measures the head circumference, and it is the same as the chest circumference. On the basis of this measurement, what action should the nurse take?

• A. Document these measurements in the infant's health care record.
• B. Tell the mother that the infant is growing faster than expected.
• C. Suggest to the health care provider that a skull x-ray be performed.
• D. Report the presence of hydrocephalus to the health care provider.

Correct answer: A

Rationale: The head circumference growth rate during the first year is approximately 0.4 inches (1 cm) per month. By 10 to 12 months of age, the infant's head and chest circumferences are equal. In this case, where the head circumference matches the chest circumference, it is a normal finding in infants around 10-12 months. Therefore, the most appropriate action is to document these measurements in the infant's health care record. Suspecting hydrocephalus or suggesting a skull x-ray would be premature and not indicated based on this measurement. Similarly, telling the mother that the infant is growing faster than expected is not accurate and could cause unnecessary concern.

3. A teenager is preparing to care for a hospitalized teenage girl who is in skeletal traction. The teenager assists with planning care knowing that which is the most likely primary concern of the teenage girl?

• A. Keeping up with schoolwork
• B. Body image
• C. Obtaining adequate rest and sleep
• D. Obtaining adequate nutrition

Correct answer: B

Rationale: The correct answer is 'Body image.' Adolescents, especially teenage girls, are often preoccupied with their appearance and body image. When facing a situation like being in skeletal traction, which can affect their physical appearance, body image becomes a primary concern. Concerns about body image can significantly impact their self-esteem and emotional well-being. Choice A, 'Keeping up with schoolwork,' is important but typically not the primary concern in this context. Choices C and D, 'Obtaining adequate rest and sleep' and 'Obtaining adequate nutrition,' are crucial for overall health but are secondary to the significant impact that body image concerns can have on a teenage girl in this situation.

4. Diagnostic genetic counseling, for procedures such as amniocentesis and chorionic villus sampling, allows clients to make all of the following choices except:

• A. terminating the pregnancy.
• B. preparing for the birth of a child with special needs.
• C. accessing support services before the birth.
• D. completing the grieving process before the birth.

Correct answer: D

Rationale: Diagnostic genetic counseling provides clients with important information to make informed decisions regarding their pregnancy. Clients can choose to terminate the pregnancy, prepare for the birth of a child with special needs, and access support services before the birth based on the genetic testing results. However, completing the grieving process before the birth is not a typical choice during genetic counseling. The grieving process, if needed, may extend beyond the prenatal period, especially if the findings are concerning or indicate potential issues. Therefore, completing the grieving process before the birth is the exception among the provided options.

5. A clinic nurse about to meet a new client plans to gather subjective data regarding the client's health history. Which action does the nurse take to help ensure the success of the interview?

• A. Ensuring that the room is private
• B. Having the client sit across from the nurse without a desk or table between them
• C. Maintaining a distance of 4 to 5 feet between the nurse and client
• D. Adjusting the room lighting to ensure it is comfortable and conducive for the client

Correct answer: A

Rationale: The physical environment of an interview room should provide optimal conditions to encourage a smooth interview and make the client feel comfortable. The nurse ensures that privacy is maintained to avoid interruptions during the interview. This helps create a safe space for the client to share sensitive information. Having the client sit across from the nurse without a desk or table between them is also important to promote open communication and build rapport. Maintaining a distance of 4 to 5 feet from the client respects their personal space and helps prevent the client from feeling overwhelmed. While adjusting the room lighting is beneficial for creating a comfortable atmosphere, ensuring privacy is crucial for establishing trust and confidentiality. Therefore, ensuring that the room is private is crucial for the success of the interview, making choice A the correct answer. Choices B, C, and D are incorrect as they do not directly address the importance of privacy in creating a conducive environment for the interview.

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