Nursing Elites

1. When performing a return demonstration of using a gait belt for a female patient with right-sided weakness, which observation indicates that the caregiver has learned the correct procedure?

• A. Standing on the female patient's strong side, the caregiver is ready to hold the gait belt if any evidence of weakness is observed.
• B. Standing on the female patient's weak side, the caregiver provides security by holding the gait belt from the back.
• C. Standing behind the female patient, the caregiver provides balance by holding both sides of the gait belt.
• D. Standing slightly in front and to the right of the female patient, the caregiver guides her forward by gently pulling on the gait belt.

Correct answer: B

Rationale: When assisting a patient with right-sided weakness using a gait belt, the caregiver must stand on the weak side of the patient to provide optimal support and security. By standing on the weak side and holding the gait belt from the back, the caregiver can effectively prevent falls and guide the patient's movements. This position allows for better control over the patient's balance. Standing on the strong side (option A) does not offer the necessary support if the patient leans towards the weak side. Standing behind the patient and holding both sides of the gait belt (option C) does not provide focused support to the weak side. Standing slightly in front and to the right (option D) may not offer adequate assistance to prevent falls on the weak side, making it an incorrect choice.

2. A teenager begins to cry while talking with the nurse about the problem of not being able to make friends. Which is the correct therapeutic nursing intervention?

• A. Sitting quietly with the client
• B. Telling the client that crying is not helpful
• C. Suggesting that the client play a board game
• D. Recommending how the client can change this situation

Correct answer: A

Rationale: The correct therapeutic nursing intervention in this situation is sitting quietly with the client. This approach conveys empathy, acceptance, and a willingness to listen, which can help the teenager feel supported and understood. It is important for the nurse to create a safe space for the client to express their emotions without judgment. Telling the client that crying is not helpful dismisses their feelings and can hinder the therapeutic relationship. Suggesting a board game as a distraction may prevent the client from fully exploring and addressing their emotions about the issue. Recommending how the client can change the situation may be premature at this stage, as the priority is to provide emotional support and establish trust before delving into problem-solving.

3. A 19-year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of 'suppression'?

• A. "I don't remember anything about what happened to me."?
• B. "I'd rather not talk about it right now."?
• C. "It's the other entire guy's fault! He was going too fast."?
• D. "My mother is heartbroken about this."?

Correct answer: A

Rationale: The correct answer is, '"I don't remember anything about what happened to me."?' Suppression involves willfully putting an unacceptable thought or feeling out of one's mind. In this case, the client is purposely choosing not to remember details of the traumatic event to avoid dealing with the associated emotions. Choice B, '"I'd rather not talk about it right now,"?' suggests avoidance or deflection rather than active suppression. Choice C, '"It's the other entire guy's fault! He was going too fast,"?' indicates blaming someone else for the situation, which is a form of defense mechanism known as externalization. Choice D, '"My mother is heartbroken about this,"?' expresses empathy towards the mother's emotions and does not demonstrate suppression of personal feelings.

4. Which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week?

• A. White blood cell count
• B. Albumin
• C. Calcium
• D. Sodium

Correct answer: D

Rationale: The nurse should monitor the client's serum sodium levels carefully when they have been on nasogastric (NG) tube suction for an extended period. Prolonged NG suctioning can lead to fluid loss and subsequent hyponatremia. Monitoring sodium levels is crucial to prevent complications. White blood cell count (Option A), albumin (Option B), and calcium (Option C) are not typically affected by prolonged NG suctioning. Therefore, these values are not the priority for monitoring in this situation.

5. During the evacuation of a group of clients from a medical unit due to a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. What action should the nurse take?

• A. Assign an unlicensed assistive person to transport the client via a wheelchair.
• B. Remind the client to walk carefully down the stairs until reaching a lower floor.
• C. Ask the client to help by assisting a wheelchair-bound client to a nearby elevator.
• D. Open the closest fire doors so that ambulatory clients can evacuate more rapidly.

Correct answer: B

Rationale: During the evacuation of a unit due to a fire, ambulatory clients should be evacuated via the stairway if possible and reminded to walk carefully to ensure their safety. They do not necessarily require assistance via a wheelchair. Elevators should not be used during a fire evacuation as they can pose a risk, and fire doors should be kept closed to contain the fire and smoke, preventing its spread to other areas of the building. Therefore, reminding the client to walk carefully down the stairs is the most appropriate action in this situation. Assigning an unlicensed assistive person to transport the client via a wheelchair may delay the evacuation process and put both individuals at risk. Asking the client to help by assisting a wheelchair-bound client to an elevator is not safe during a fire evacuation. Opening fire doors indiscriminately can lead to the spread of fire and smoke, endangering the clients and staff further.

Similar Questions