Nursing Elites

1. The nurse is comparing the concepts of religion and spirituality. Which statement describes an appropriate component of one's spirituality?

• A. Belief in and worship of God or gods
• B. Being closely tied to one's ethnic background
• C. Attendance at a specific church or place of worship
• D. A connection with something larger than oneself and belief in transcendence

Correct answer: D

Rationale: Spirituality refers to a connection with something larger than oneself and a belief in transcendence. The other responses do not apply to spirituality. Choice A, 'Belief in and worship of God or gods,' and choice C, 'Attendance at a specific church or place of worship,' are more aligned with religious practices. Choice B, 'Being closely tied to one's ethnic background,' is not a defining aspect of spirituality or religion as it pertains more to cultural identity rather than spiritual beliefs.

2. While performing the physical examination, why does the nurse share information and briefly teach the patient?

• A. To help the patient feel more comfortable and gain control of the situation
• B. To build rapport and increase the patient's confidence in the examiner
• C. To assist the patient in understanding his or her disease process and treatment modalities
• D. To aid the patient in identifying questions about his or her disease and potential areas of needed education

Correct answer: B

Rationale: Sharing information and briefly teaching the patient during a physical examination helps build rapport and increase the patient's confidence in the examiner. This approach gives the patient a sense of control in a situation that can often be overwhelming. While sharing information may make the patient feel more comfortable, the primary goal is to enhance the patient's confidence in the examiner. Providing information does not necessarily directly assist the patient in understanding their disease process and treatment modalities, as this may require a more in-depth explanation. The main focus is on establishing a trusting relationship and empowering the patient during the examination, rather than solely aiding in identifying questions or areas needing education.

3. Mrs. D is a pregnant client who is 33 weeks' gestation and is admitted for bright red vaginal bleeding. Her physician suspects placenta previa. All of the following nursing interventions are appropriate for this client except:

• A. Institute complete bed rest for the client
• B. Assess uterine tone to determine condition
• C. Perform a vaginal exam to assess cervical dilation
• D. Measure and record blood loss each shift

Correct answer: C

Rationale: A client with placenta previa has part of the placenta covering some or all of the cervical opening. Performing a vaginal exam for placenta previa may cause significant bleeding and should be avoided unless directed by a physician, and preparations are made for emergency delivery. **Choice A** is correct as complete bed rest is essential to decrease the risk of further bleeding. **Choice B** is appropriate as assessing uterine tone helps in determining the condition of the uterus and can provide important information for the healthcare team. **Choice D** is also a necessary intervention as monitoring and recording blood loss is crucial in assessing the client's condition and response to treatment.

4. A 2-year-old child has been brought to the clinic for a well-child checkup. What is the best way for the nurse to begin the assessment?

• A. Ask the parent to place the child on the examining table.
• B. Have the parent remove all of the child's clothing before the examination.
• C. Allow the child to keep a security object such as a toy or blanket during the examination.
• D. Initially focus the interactions on the child, essentially ignoring the parent until the child's trust has been obtained.

Correct answer: C

Rationale: The best place to examine the toddler is on the parent's lap. Toddlers understand symbols; therefore, a security object is helpful. Initially, the focus is more on the parent, which allows the child to adjust gradually and to become familiar with you. A 2-year-old child does not like to take off his or her clothes. Therefore, ask the parent to undress one body part at a time.

5. Which of the following is recommended by Joint Commission guidelines regarding the use of restraints?

• A. Vest restraints should be used because they are the least restrictive type.
• B. Restraints should be used for 48 hours in non-psychiatric patients.
• C. Restraints should be applied to prevent wandering behavior.
• D. Alternative measures must be attempted first.

Correct answer: D

Rationale: When considering the use of restraints, Joint Commission guidelines emphasize the importance of attempting alternative measures before resorting to restraint application. This ensures that a comprehensive assessment is conducted and less restrictive interventions are explored. Using restraints solely based on their perceived level of restrictiveness, as stated in choice A, is not in line with the recommended approach. Restraints should not be used to manage wandering behavior, as indicated in choice C. Additionally, the statement in choice B regarding the duration of restraint use is inaccurate, as restraints on non-psychiatric patients should not exceed 24 hours according to The Joint Commission.

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