Nursing Elites

1. The healthcare professional needs to validate which of the following statements pertaining to an assigned client?

• A. The client has a hard, raised, red lesion on his right hand.
• B. A weight of 185 lbs. is recorded in the chart.
• C. The client reported an infected toe.
• D. The client's blood pressure is 124/70.

Correct answer: C

Rationale: Validation is the process of confirming that data are actual and factual. Data that can be measured can be accepted as factual, as in options 1, 3, and 4. The weight, blood pressure, and physical appearance of a lesion can be objectively verified. However, option C, the client reporting an infected toe, requires the nurse to directly assess the client's toe to confirm the statement. This choice involves subjective data that needs to be validated through direct observation, making it the correct answer. Options A, B, and D provide data that can be measured objectively and verified without the need for further assessment.

2. Mr. N is a client who entered the hospital with a diagnosis of diabetic ketoacidosis. The nurse enters his room to check his vital signs and finds him breathing at a rate of 32 times per minute; his respirations are deep and regular. Which type of respiratory pattern is Mr. N most likely exhibiting?

• A. Kussmaul respirations
• B. Cheyne-Stokes respirations
• C. Biot's respirations
• D. Cluster breathing

Correct answer: A

Rationale: Mr. N is exhibiting Kussmaul respirations, characterized by rapid, deep, and regular breathing. This type of respiratory pattern is commonly seen in metabolic acidosis, such as in diabetic ketoacidosis. Kussmaul respirations are a form of hyperventilation, leading to the elimination of carbon dioxide from the body. Choice B, Cheyne-Stokes respirations, is characterized by alternating periods of deep, rapid breathing followed by periods of apnea and is not typically associated with diabetic ketoacidosis. Choice C, Biot's respirations, involve irregular breathing patterns with periods of apnea and are not reflective of the described breathing pattern. Cluster breathing, as mentioned in Choice D, is not a recognized term in respiratory patterns and does not describe the breathing pattern observed in Mr. N.

3. Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB. Which information should the occupational health nurse plan to teach the staff nurse?

• A. Standard four-drug therapy for TB
• B. Need for annual repeat TB skin testing
• C. Use and side effects of isoniazid (INH)
• D. Bacille Calmette-Gurin (BCG) vaccine

Correct answer: C

Rationale: The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for individuals who have already had a positive skin test. BCG vaccine is not used in the United States for TB and would not be helpful for this individual, who already has a TB infection.

4. An 18-year-old male patient informs the nurse that he isn't sure if he is homosexual because he is attracted to both genders. The nurse establishes a trusting relationship with the patient by saying:

• A. Don't worry. It's just a phase you will grow out of.
• B. Those are abnormal impulses. You should seek therapy.
• C. At your age, it is normal to be curious about both genders.
• D. Having questions about sexuality is normal. Have you noticed any changes in the way this makes you feel about yourself?

Correct answer: C

Rationale: It is important for the nurse to validate the patient's concerns and provide a supportive environment. By acknowledging that it is normal for young adults to have questions about sexuality, the nurse helps the patient feel understood and accepted. This response encourages further discussion and exploration of the patient's feelings without judgment. Choice A dismisses the patient's concerns and implies that his feelings are not valid. Choice B stigmatizes the patient's feelings by labeling them as abnormal and suggests therapy without proper assessment. Choice D addresses the patient's feelings but lacks the validation and reassurance present in the correct answer, which is essential in building a trusting relationship with the patient.

5. Which method is most appropriate for managing moral distress in the workplace?

• A. Recognizing that life is unfair and nurses cannot meet every need of every client
• B. Declining to act when clients or visitors make requests that are not justifiable
• C. Developing a new policy that would address the problematic situation
• D. Both A and B

Correct answer: C

Rationale: Moral distress involves negative feelings or frustration toward situations that are deemed unfair, unethical, or that cause the nurse to feel helpless in their work. It can lead to nurse burnout when ongoing issues are not resolved. The most appropriate method for managing moral distress is to develop new policies that address the problematic situations. By creating policies, nurses can work towards changing current standards and reducing the number of situations that lead to moral distress. Choices A and B are incorrect because recognizing life's unfairness and not taking action on unjustifiable requests do not actively address the root causes of moral distress or work towards resolving the issues.

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