Nursing Elites

1. The nurse observes bilateral bruises on the arms of an elderly client in a long-term care facility. Which of the following questions should the nurse ask this client?

• A. "How did you get those bruises?"?
• B. "Did someone grab you by your arms?"?
• C. "Do you fall often?"?
• D. "What did you bump against?"?

Correct answer: B

Rationale: When addressing suspected abuse, it is crucial to ask direct questions to determine the cause of injuries. Choice B is the most appropriate as it directly inquires about the possibility of someone grabbing the client's arms, which could indicate abuse. This question can help uncover potential abuse and provide necessary intervention. Choices A, C, and D are less direct and may not elicit the critical information needed to address abuse effectively. Clients often hesitate to report abuse due to feelings of shame and fear of retaliation, making a direct approach essential in such situations.

2. When supporting a family who has just experienced a sudden and unexpected death, the nurse needs to know:

• A. that survivors have greater emotional turmoil and shock than when death is expected.
• B. that survivors have less emotional turmoil and shock than when death is expected.
• C. that survivors have the same emotional turmoil and shock as when death is expected.
• D. that survivors have little emotional turmoil and shock because they were not there.

Correct answer: A

Rationale: The correct answer is that survivors have greater emotional turmoil and shock than when death is expected. Sudden death produces more emotional turmoil and shock in survivors compared to gradual, expected death. Survivors of sudden death do not have the opportunity to engage in anticipatory grief. The unexpectedness of sudden death is the most disturbing and unbalancing factor, leading to heightened emotional turmoil and shock. Choice B is incorrect as survivors of sudden death experience more emotional turmoil and shock. Choice C is incorrect because sudden death brings about a different level of emotional turmoil and shock. Choice D is incorrect as survivors of sudden and unexpected death still go through significant emotional distress.

3. The nurse is working with families who have been displaced by a fire in an apartment complex. What is the priority intervention during the initial assessment?

• A. Provide a liaison to meet housing needs.
• B. Attentively listen when clients describe their feelings.
• C. Offer nurturing support for clients who are confused by the events.
• D. Provide structure for clients exhibiting moderate to severe anxiety.

Correct answer: A

Rationale: The correct answer is to provide a liaison to meet housing needs. In the initial assessment after a disaster like a fire, ensuring basic needs such as housing, clothing, and food are met is the priority. Once the physical needs are addressed, the nurse can then focus on assisting clients in managing the psychological effects of loss. Choices B, C, and D are not the priority during the initial assessment as addressing housing needs should come first to provide a sense of stability and security for the affected families.

4. The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which laboratory value might indicate a serious side effect of this drug?

• A. Uric acid of 5 mg/dL
• B. Hematocrit of 33%
• C. WBC 2,000 per cubic millimeter
• D. Platelets 150,000 per cubic millimeter

Correct answer: C

Rationale: Carbamazepine (Tegretol) can suppress the bone marrow, leading to a decrease in the white blood cell count. A laboratory value of WBC 2,000 per cubic millimeter indicates a serious side effect of the drug. Choices A and D are within normal limits, while choice B is at the lower limit of normal. Therefore, choices A, B, and D are incorrect.

5. In which age group does the highest incidence of child abuse occur?

• A. Birth-3 years old
• B. 4-6 years old
• C. 6-10 years old
• D. More than 10 years old

Correct answer: A

Rationale: The correct answer is 'Birth-3 years old.' Children between birth and 3 years of age have the highest rates of victimization (at 16 per 1,000 children). This age group is most vulnerable due to their dependency and inability to report or protect themselves effectively. Child abuse can occur at any age, but statistics show that infants and toddlers are at the highest risk due to their developmental stage and reliance on caregivers. Choices B, C, and D are incorrect because while child abuse can happen at any age, the prevalence is highest among children in the 0-3 age group.

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