Nursing Elites

1. The client admitted for uncontrolled diabetes is worried about how to pay bills for the family while hospitalized. Which statement by the nurse is therapeutic?

• A. "You are worried about paying your bills?"
• B. "Don't worry; your bills will get paid eventually."
• C. "When was the last time you were admitted for hyperglycemia?"
• D. "You really shouldn't be drinking alcohol because of your diagnosis of diabetes."

Correct answer: A

Rationale: The therapeutic communication technique used in this scenario is reflection. By repeating the client's concern, the nurse acknowledges the client's feelings and encourages further exploration of the topic. Choice A is correct as it reflects the client's worry without offering false assurance, advice, or using professional jargon. Choice B dismisses the client's concerns with false reassurance. Choice C introduces professional jargon, which may hinder effective communication. Choice D provides advice, which can limit the client's expression of feelings and concerns.

2. A client says, 'I hear a man speaking from the corner of the room. Do you hear him, too?' Which response is best?

• A. What is he saying to you? Does it make any sense?
• B. Yes, I hear him. What do you think he is saying?
• C. No one is in the corner of the room. Can't you see that?
• D. No, I don't hear him, but that must be upsetting for you.

Correct answer: D

Rationale: The best response is D: 'No, I don't hear him, but that must be upsetting for you.' This response acknowledges the client's experience without validating the hallucination. The nurse expresses empathy by acknowledging the client's feelings ('that must be upsetting for you'), showing understanding and support. Choice A focuses on the content of the hallucination, which may inadvertently reinforce the delusion. Choice B validates the hallucination by agreeing that the nurse also hears the man. Choice C denies the client's experience and can lead to further distress by invalidating their perception.

3. Nursing behaviors associated with the implementation phase of the nursing process are concerned with:

• A. participating in the mutual identification of patient outcomes.
• B. gathering accurate and sufficient patient-centered data.
• C. comparing patient responses and expected outcomes.
• D. carrying out interventions and coordinating care.

Correct answer: D

Rationale: During the implementation phase of the nursing process, nurses focus on executing interventions and coordinating care. This involves utilizing available resources, performing necessary interventions, exploring alternatives when needed, and collaborating with other healthcare team members to ensure comprehensive care delivery. Choice A is incorrect as it pertains more to the planning phase where patient outcomes are identified. Choice B is incorrect as it relates to data collection, which is primarily a part of the assessment phase. Choice C is incorrect as it involves evaluating patient responses against expected outcomes, which is part of the evaluation phase.

4. The client with cholecystitis is being instructed about dietary choices. Which meal best meets the dietary needs of this client?

• A. Steak, baked beans, and a salad
• B. Broiled fish, green beans, and an apple
• C. Pork chops, macaroni and cheese, and grapes
• D. Avocado salad, milk, and angel food cake

Correct answer: B

Rationale: Clients with cholecystitis, which is inflammation of the gallbladder, should follow a low-fat diet to reduce symptoms. Broiled fish, green beans, and an apple (Option B) is the most suitable choice as it is low in fat. Steak, baked beans, and a salad (Option A) provide a high amount of fat and protein, which may exacerbate symptoms of cholecystitis. Pork chops, macaroni and cheese, and grapes (Option C) and avocado salad, milk, and angel food cake (Option D) contain high-fat foods that are not recommended for individuals with cholecystitis. Therefore, Option B is the most appropriate choice for a client with cholecystitis.

5. When observing an infant lying quietly in the bassinet with eyes open wide, what action should the nurse take in response to the infant's behavior?

• A. Brightening the lights in the room
• B. Encouraging the mother to talk to her baby
• C. Wrapping and then turning the infant to the side
• D. Beginning physical and behavioral assessments

Correct answer: B

Rationale: When an infant is lying quietly in a bassinet with eyes open wide, it indicates a quiet, alert state. This state is optimal for infant stimulation and interaction. Bright lights can be disturbing to newborns and may disrupt the mother-infant interaction. Wrapping and turning the infant to the side is typically done for a sleeping infant. While physical and behavioral assessments are important, in this scenario, the priority is to encourage mother-infant bonding and communication, as it is a valuable opportunity for interaction and stimulation.

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