Nursing Elites

1. The nurse suspects an elderly client has been the victim of abuse. The client denies abuse and declines assistance. The nurse's next action should be to:

• A. respect the client's decision to refuse assistance.
• B. report the incident to the authorities.
• C. arrange an appointment with the client's family.
• D. educate the client about available services.

Correct answer: D

Rationale: In cases where elderly clients deny abuse and refuse assistance, it is crucial for the nurse to respect their autonomy while also ensuring their safety. Educating the client about available services is the appropriate action as it empowers the client with information without imposing any decisions on them. It allows the client to make informed choices regarding their well-being. Reporting the incident to the authorities (Choice B) may be necessary if there is immediate danger, but in this scenario, the client denies abuse. Arranging an appointment with the client's family (Choice C) may not be appropriate without the client's consent or in cases where the family might be involved in the abuse. Simply doing nothing (Choice A) is not the best course of action as the nurse should still provide support and resources to the client.

2. What should the charge nurse do after overhearing the patient care assistant speaking harshly to the client with dementia?

• A. Change the patient care assistant's assignment
• B. Explore the interaction with the patient care assistant
• C. Discuss the matter with the client's family
• D. Initiate a group session with the patient care assistant

Correct answer: B

Rationale: The best action for the charge nurse to take is to explore the interaction with the patient care assistant. This step allows for clarification of the situation and direct addressing of the issue. Changing the patient care assistant's assignment (choice A) might be necessary, but understanding the situation should come first. Discussing the matter with the client's family (choice C) as an initial step could escalate the situation. Initiating a group session with the patient care assistant (choice D) could be considered later as a preventive measure to avoid similar incidents in the future.

3. A client asks the nurse if all donor blood products are cross-matched with the recipient to prevent a transfusion reaction. Which of the following always requires cross-matching?

• A. packed red blood cells
• B. platelets
• C. plasma
• D. granulocytes

Correct answer: A

Rationale: Corrected Rationale: Packed red blood cells contain antigens and antibodies that must be matched between the donor and recipient to prevent transfusion reactions. Platelets, plasma, and granulocytes do not contain red blood cells, so they do not require cross-matching. Platelets are matched based on ABO compatibility, while plasma and granulocytes are not routinely cross-matched as they lack red cell antigens.

4. A 6-month-old client is admitted with possible intussusception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?

• A. "Tell me about his pain."?
• B. "What does his vomit look like?"?
• C. "Describe his usual diet."?
• D. "Have you noticed changes in his abdominal size?"?

Correct answer: C

Rationale: The least helpful question in obtaining information regarding intussusception is "Describe his usual diet."? This question is least relevant to the specific symptoms and presentation of intussusception. Choices A, B, and D are more directly related to symptoms commonly associated with intussusception and can provide important diagnostic clues. Asking about pain, vomit appearance, and changes in abdominal size can help in assessing the severity and progression of the condition, making them more crucial questions to ask in this scenario. Pain is a cardinal symptom of intussusception, changes in vomit appearance may indicate gastrointestinal issues, and alterations in abdominal size can signify the presence of a mass or obstruction, all of which are pertinent in diagnosing and managing intussusception.

5. In the emergency room, a nurse is responsible for triaging four clients injured in a motor vehicle accident. Which of the following clients should receive priority in care?

• A. A 10-year-old with lacerations on the face
• B. A 15-year-old with sternal bruises
• C. A 34-year-old with a fractured femur
• D. A 50-year-old with a dislocated elbow

Correct answer: B

Rationale: The 15-year-old with sternal bruises should receive priority in care as this client might be experiencing airway and oxygenation problems. Airway issues take precedence in triage. The 10-year-old with lacerations on the face, although looking bad, is not in immediate distress. The 34-year-old with a fractured femur should be immobilized but can be seen after the client with sternal bruising. The 50-year-old with a dislocated elbow can also be seen later as dislocated elbows are not life-threatening compared to potential airway compromise.

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